Apply for AFFIRM2

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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:

Hemophilia A & B all severities
VWD 2A, 2B, or 2N
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:

Email: ekueblerconsulting@gmail.com

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.

*Personal Essay: Type a brief essay in your own words, explaining your interest in joining AFFIRM. Describe why you are a good candidate and what you hope to gain by participating. Include information about your interests and activities, past achievements and future ambitions, specific professional and educational plans, and any other information that will be useful in assessing your suitability. The length of your essay should be a minimum of 500 words.

SECTION 6: RELEASE OF INFORMATION/LIKENESS AND CONTACT INFORMATION

I give permission to HemLEAD Faculty, the Global Blood Disorder Foundation Inc, in accordance with the laws and guidelines of my country, to provide my contact details to global, regional and local patient support societies, associations and organizations for purposes including additional training, mentorship, and leadership and promotional opportunities.

I give my permission to HemLEAD Faculty, the Global Blood Disorder Foundation Inc, in accordance with the laws and guidelines of my country, to contact me regarding local activities and events of interest (e.g., speaking opportunities, traditional or social media, etc.). I understand that my permission does not represent a commitment to participate in any particular activity and I may revoke it at any time.

I give my permission to HemLEAD Faculty, the Global Blood Disorder Foundation Inc, in accordance with the laws and guidelines of my country, to use photographs and video of me during AFFIRM sessions and activities in publications or pamphlets for promotion of this program by organizer and sponsor, respectively.

I give my permission to HemLEAD Faculty, the Global Blood Disorder Foundation Inc, to share or publish my projects and presentations from AFFIRM sessions and activities with other entities (e.g., global, regional and local patient support societies, associations and organizations) for purposes including medical congresses and publication.

By submitting your application, you grant permission for any photographs or video taken of you during the AFFIRM sessions and activities, and any that you may take related to program activities, to be used in publications or pamphlets for further promotion of this program by the Global Blood Disorder Foundation Inc. and HemLEAD Faculty.

SECTION 7: DISCLAIMER OF ACCEPTANCE

Applicant acceptance is at the sole discretion of the AFFIRM selection committee. The Committee consists of representatives from the Global Blood Disorder Foundation Inc. and HemLEAD Faculty.