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GBDF
Global Blood Disorder Foundation
Sobre Nosotros
Nuestra misión
Trastornos hemorrágicos
Programas
Events
Step Up Reach Out (SURO)
LatAm SURO
International AFFIRM
Junta Directiva
Attendees
SURO
2020-2021
AFFIRM
2020-2021
Video
Recursos
Global Resources
Region Resources
Presentar su solicitud
SURO
AFFIRM
LatAm SURO
Contact Us
GBDF Platform
Login
Register
Sobre Nosotros
Nuestra misión
Trastornos hemorrágicos
Programas
Events
Step Up Reach Out (SURO)
LatAm SURO
International AFFIRM
Junta Directiva
Attendees
SURO
2020-2021
AFFIRM
2020-2021
Video
Recursos
Global Resources
Region Resources
Presentar su solicitud
SURO
AFFIRM
LatAm SURO
Contact Us
GBDF Platform
Login
Register
SECTION 1: PERSONAL INFORMATION
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Sakartvelo
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
SECTION 2: EMERGENCY CONTACT
SECTION 3: MEDICAL INFORMATION
Do you have any limited mobility or require any special services?
Yes
No
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Sakartvelo
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
On Demand
Prophylaxis
SECTION 4: TRAVEL INFORMATION
Do you have a Passport?
Yes
No
Require a VISA to travel ?
Yes
No
Not Sure
SECTION 5: ADDITIONAL INFORMATION REQUIRED TO PROCESS YOUR APPLICATION
1. Upload Letter of reference
1. Upload File
1. Upload Letter of reference
1. Upload File
2. A Letter of Diagnosis.
2. Upload File
2. A Letter of Diagnosis.
2. Upload File
3. Personal Essay
3. Upload File
3. Personal Essay
3. Upload File
4. Letter of support
4. Upload File
4. Letter of support
4. Upload File
5. Headshot
5. Upload File
5. Headshot
5. Upload File
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
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