Hemophilia Federation of America Annual Meeting & Symposium

The Peabody Hotel • Little Rock, Arkansas
May 2-3, 2008

SCHOLARSHIP APPLICATION

If you will be attending the HFA Symposium for the first time in 2008, you may qualify for a Symposium Scholarship. The scholarship pays for transportation to and from the event city (Little Rock, AR) OR lodging at the hotel. The scholarship does NOT, however, pay for the Registration Fee ($25 for a single registration, $50 for a family).

In order to be considered for a Symposium Scholarship, you must first submit a completed Registration Form and pay the appropriate registration fee. Information submitted on this Scholarship Application should match information provided for the Registration Form.

This form is intended to be completed and submitted online. Please follow instructions carefully to ensure your registration is properly submitted to us. All parts preceded by a "*" are required.

Applicant Information

*Gender

*First Name

Middle Initial

*Last Name

*Address

*City

*State

*Zip

*Home Phone

Work Phone

Cell Phone

*Email Address

Relation to Hemophilia/Other Bleeding Disorder

Do you have an Inhibitor? Yes No

*Type of Registration

List the full names of all family members attending Symposium:

Scholarship Information

*Type of Assistance Needed

If you requested travel, indicate type:

If "Other," please specify:

If "Air," please specify first choice of departing city/airport:

If "Air," please specify second choice of departing city/airport:

If "Air," please specify preferred departure time:

*Are you or your spouse employed by a Homecare Company or Manufacturer? Yes No

If "Yes," please identify Company:

*Have you previously received a HFA Symposium scholarship? Yes No

How did you find out about the HFA Symposium?

Hemophilia Federation of America Annual Meeting & Symposium

The Peabody Hotel • Little Rock, Arkansas May 2-3, 2008

SCHOLARSHIP APPLICATION

The Peabody Hotel • Little Rock, Arkansas
May 2-3, 2008