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APPLY NOW

Application Deadline : January 25th, 2019

Before Applying:

Check to ensure you meet the criteria listed. Prepare the following pieces of your application:

  • A letter of diagnosis from your medical team (physician or nurse), stating what your bleeding diagnosis is and on average how often in a year you treat for bleeding episodes excluding Stimate/Amicar and or iron replacement.
  • One letter of support from your local foundation, association or chapter
  • A personal essay, explaining in your own words your interest in joining AFFIRM
  • The information needed to complete the application form

AFFIRM Applicant Criteria:

To be considered for this program, you must meet the following requirements:

Diagnosed with a bleeding disorder (symptomatic for any bleeding disorder) which will include:

  1. Hemophilia A & B all severities
  2. VWD 2A, 2B, or 2N
  3. VWD Type 3

Severe VWD Type 1A VWD diagnosis included above to qualify will have a history of having to treat bleeding events with medication(s) other than : Stimate/Amicar and or iron replacement.

  • Between the ages of 26 and 38
  • Able to self-infuse your factor concentrate and have access to factor for the duration of conference dates (no factor or infusion assistance can be provided during the program)
  • Proficient in written and spoken English
  • Able to attend all program sessions
  • Able to travel unaccompanied and with appropriate visa and/or passport
  • Able to fulfill all aspects of the program’s application process

 

Can’t Complete the Application Online?

We encourage applicants to fill out our online application. If you cannot fill out the online application, you may download a PDF of the AFFIRM application here. Submit it, along with your letters of reference via:

SECTION 1: PERSONAL INFORMATION

SECTION 2: EMERGENCY CONTACTS

SECTION 3: MEDICAL INFORMATION

How long have you attended this treatment center?
Do you have limited mobility or require any special services? *
YesNo
SECTION 4: TRAVEL INFORMATION

Do you have a valid passport? *
YesNo
SECTION 5: ADDITIONAL INFORMATION REQUIRED TO PROCESS YOUR APPLICATION
Before Applying:


*At least one letter of reference from a care provider, employer or others able to recommend your participation.

*One letter of support from your local foundation, association or chapter.
SECTION 6: RELEASE OF INFORMATION/LIKENESS AND CONTACT INFORMATION

SECTION 7: DISCLAIMER OF ACCEPTANCE