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Aplica ya

Application Deadline : January 30, 2022

Personal Information

  • Please use your name as it appears on your Passport in filling out this application
  •  Please be sure you have an email that is working, you are checking regularly, and is easily able to identify you (no nicknames or letters that can confuse the Application Reviewer as to who you are in your email address). If needed create a new email that identifies you by your name.

Antes de presentar su solicitud:

Be sure you meet all the criteria listed

  • An incomplete application will not be considered.
  • All Selected Applicants will have a virtual interview set up as the last part of being accepted into the International AFFIRM Program.

Afirmación de los criterios del solicitante:

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

  • Males and Females
  • VWD type 3
  • VWD type 2 requires regular treatment or prophylaxis.
  • Glanzmann’s Thrombasthenia
  • Bernard-Soulier Syndrome
  • Other platelet function defects require regular treatment or prophylaxis.
  • Afibrinogenemia
  • Factors II, V, VII, VIII, IX, X, XI, and XIII requires regular treatment or prophylaxis.
  • Between the ages of 26 and 38 (no exceptions)
  • Access to factor for the duration of the conference.
  • No factor or infusion assistance will be provided for the duration of conference dates.
  • Proficient in written and spoken English (no exceptions)
  • Capaz de asistir a todas las sesiones del programa.
  • Capaz de viajar sin acompañante y con visa y / o pasaporte apropiados
  • Able to fulfill all aspects of the program criteria and understand what is being asked of you.
  • A letter of diagnosis from your medical team (physician or nurse) confirming your bleeding disorder diagnosis including severity.
  • A letter of support from your local foundation, chapter, or association. Acknowledging their support of you being in the AFFIRM Program
  • A letter of support from a person who can attest to your leadership abilities and be able to meet the goals and responsibilities of a leadership program. This
    person can be a teacher or professor, employer, etc. It cannot be a family member!
  • A personal essay describing your interest, qualifications, and reason why you should be selected to be in the International AFFIRM Program. A minimum of 500 words is expected.
  • Completion of the online application
  • To be considered for this program, you MUST meet all the criteria listed above!

¿No puede completar la solicitud en línea?

Unable to Complete the Application? 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 aquí. Submit it with your supporting documentation.

    SECCIÓN 1: INFORMACIÓN PERSONAL

    SECCIÓN 2: CONTACTOS DE EMERGENCIA

    SECCION 3: INFORMACIÓN MÉDICA

    ¿Cuánto tiempo ha asistido a este centro de tratamiento?
    Do you have any limited mobility or require any special services? *
    No
    Treatment Regiment (chose one)*
    SECCIÓN 4: INFORMACIÓN DE VIAJE

    ¿Tienes un pasaporte válido? *
    No
    Do you require a VISA to travel from your country? *
    : - ( check your countries requirements so you have this information when traveling to the AFFIRM Program Meeting location). The cost of a VISA is not covered by the program!
    SECCION 5: INFORMACIÓN ADICIONAL REQUERIDA PARA PROCESAR SU SOLICITUD
    Antes de presentar su solicitud:


    * Al menos una carta de referencia de un maestro, proveedor de atención, empleador u otras personas que puedan recomendar su participación.

    * Una carta de apoyo de su fundación o asociación local.

    *A Letter of Diagnosis.


    *Upload a clear Headshot, It should cover 80% of your face, A reference image is attached aquí.

    SECCIÓN 6: DIVULGACIÓN DE INFORMACIÓN / PROBABILIDAD E INFORMACIÓN DE CONTACTO

    I understand I must have factor concentrate available for me to bring to the AFFIRM Program Meetings in the event of a bleed and/or emergency.
    I understand, failure to bring factor concentrate or my treating medication with me to the AFFIRM Program Meetings will be caused to be dismissed from the program.
    SECCIÓN 7: RENUNCIA DE ACEPTACIÓN