*Province: *Postal Code: *Home Phone: Cell /Other Phone: ... Please send me details. I would like to learn more about: â
Hemophilia Ontario (HO) Membership Registration Form Membership fees: $0
Date: __________________________________
Please print legibly * Required *Name: *Address: P.O. Box: *City: *Province: *Postal Code: *Home Phone: Cell /Other Phone: Email: I would like to give my consent to receive correspondence from Hemophilia Ontario by: □ Email □ Twi er □ Facebook □ Post Mail Preferred contact: □ Email □ Phone □ Post Mail □ Other _______ *Signature: I wish to be on the Hemophilia Ontario email list, please check the box: Yes □ No □ I wish to be on the regional email list, please check the box: Volunteer List □ CWOR □ NOR □ OEOR □ SWOR □ TCOR Yes □ No □ If you do not wish to receive the following free magazines, please check appropriate box: □ Blood Matters Newsmagazine □ Hemophilia Today (CHS magazine)
An online registration form is also available at http://www.hemophilia.ca/en/provincial‐chapters/ontario/about‐our‐chapter/. Additional information can be obtained by contacting Hemophilia Ontario. See http://hemophilia.on.ca
Type of member * Regular member (Persons diagnosed with an inherited bleeding disorder and/or immediate family members (spouse, parents, children, siblings and grand‐parents) of those diagnosed) Associate member (Individuals desiring to support the above stated mission of the Hemophilia Ontario and CHS, and whose names appear on the membership list thirty days prior to the Annual General Meeting)
Supplemental information ** Voluntary, not required. All personal information collected is so that we may better inform you of relevant programs and activities, and will be kept strictly confidential. Please check all that apply: □ Male □ Female □ Other ____________________ Language Preferred □ English □ French □ Other ____________________ □ Between 18‐25 years of age Year of birth (to know when no longer a youth) ___ □ Hemophilia □ von Willebrand Disease □ Platelet Disorder □ Factor Deficiency □ Non‐affected Help us ensure you are receiving the information that interests you, please check all that apply: I would like to receive details about regional and provincial programs as follows: Children’s programs (0‐15 yrs) including camps Youth programs (16‐25 yrs) Men’s programs Women’s programs Parents’ programs Family networking opportunities HCV programs HIV programs Bursaries & Scholarships I would like to learn more about: Hemophilia Carriers CODErouge Von Willebrand disease Platelet function disorders Rare factor deficiencies HIV HCV Other___________________________ I would like to help Hemophilia Ontario □ I am interested in learning more about becoming involved as a volunteer. Please contact me. □ I would like to help with fundraising to ensure the continuation of educational and member networking programs □ I would like to become a monthly donor. Please send me details.
