suro-logo

APPLY NOW

Application Deadline : July 28th, 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 Step Up Reach Out
  • The information needed to complete the application form

SURO Applicant Criteria:

To be considered for this program, you must meet the following requirements: Diagnosed with a bleeding disorder which will include:

  • Hemophilia A & B all severities
  • Between the ages of 18 and 25
  • 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)
  • 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 SURO application here. Submit it, along with your letters of reference via:

    SECTION 1: PERSONAL INFORMATION

    SECTION 2: EMERGENCY CONTACTS

    SECTION 3: MEDICAL INFORMATION

    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 teacher, 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