Patient/Caregiver Scholarship Application

Number of Adults *

Number of Children *

Please list names of attendees below *

How are you affected by a bleeding disorder? *

Patient Caregiver Other

Type of bleeding disorder *

Hemophilia A (VIII) Hemophilia B (IX) vWD Other

Are you requesting assistance with covering the cost of your hotel stay? *

Yes No

Rooms Request *

If yes, please provide details of your accommodations requested *

**We will do our best to accommodate you in the requested order, however we may have to ask you to stay in a room type other than requested due to limited availability.

Are you requesting assistance with covering the cost of your airfare? *

Yes No

If yes, please provide preferred airport & times *

Are you requesting assistance with mileage reimbursement? *

Yes No

If yes, please provide approximate milage requested? *

By applying for travel assistance you understand that Hope for Hemophilia is not responsible for any expenses outside of the approved arrangements, delays and/or lost luggage or any other associated expenses other than those expressly stated in your approval letter. Hope for Hemophilia takes privacy very seriously and will not share any of your personal information. By signing this application you understand that Hope for Hemophilia will add you to our mailing list for future invitations to future events and mailings. If your application is approved Hope for Hemophilia requests that you participate in all available sessions and training throughout the event unless otherwise medically excused. This application does not guarantee approval for assistance and could be denied. All applications must be completed and submitted no later than September 16th, 2018 to be considered for approval.

PRELIMINARY SCHEDULE