SURO Test

SECTION 1: PERSONAL INFORMATION

SECTION 2: EMERGENCY CONTACT

SECTION 3: MEDICAL INFORMATION

Do you have any limited mobility or require any special services?

YesNo

SECTION 4: TRAVEL INFORMATION

SECTION 5: ADDITIONAL INFORMATION REQUIRED TO PROCESS YOUR APPLICATION

1. Upload Letter of reference

1. Upload File

2. A Letter of Diagnosis.

3. Personal Essay

4. Letter of support

5. Headshot

SECTION 6: RELEASE OF INFORMATION/LIKENESS AND CONTACT INFORMATION

I give permission to Global Blood Disorder Foundation Program 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.

Agree

I give my permission to Global Blood Disorder Foundation Program Faculty, the Global Blood Disorder Foundation Inc., In accordance with the laws and guidelines of my country, 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 activity and I may revoke it at any time.

Agree

I give my permission to Global Blood Disorder Foundation Program 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 Step Up Reach Out sessions and activities in publications or pamphlets for promotion of this program by the organizer, sponsor respectively.

Agree

I give my permission to Global Blood Disorder Foundation Program Faculty, the Global Blood Disorder Foundation Inc., to share or publish my projects and presentations from Step Up Reach Out 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.

Agree

I give my permission to Global Blood Disorder Foundation Program 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 activity and I may revoke it at any time.

Agree

I understand I must have factor concentrate available for me to bring to the SURO Program Meetings in the event of a bleed and/or emergency.

Agree

I understand, failure to bring factor concentrate or my treating medication with me to the SURO Program Meetings will be caused to be dismissed from the program.

Agree

I understand I may need to be vaccinated/Treated to attend the SURO program.

Agree

I understand to attend the International SURO Program, I will need to purchase Travel Insurance at my own expense and provide proof on that document

Agree

SECTION 7: DISCLAIMER OF ACCEPTANCE

La aceptación del solicitante queda a criterio exclusivo del comité de selección de SURO Latam. El Comité está formado por representantes de Global Blood Disorder Foundation Inc., el cuerpo docente del programa de Global Blood Disorder Foundation en la comunidad de trastornos hemorrágicos.

Solo completa si no eres humano