*1.Person completing registration form:(Required.)

Name: *

Address: *

Address 2:

City/Town: *

State: *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP: *

Email Address: *

Phone Number: *

*2.County of residence?(Required.)

Select one:

County

AdamsAllenBartholomewBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFultonFranklinGreeneGibsonGrantHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLaPorteLakeLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNobleNewtonOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushPutnamSt JosephScottShelbySpencerStarkeSteubenSullivanSwitzerlandTippecanoeTiptonUnionVanderburghVermillionVigoWabashWarrenWarrickWashingtonWayneWellsWhiteWhitleyOther

*3.Have you or an immediate family member living in the SAME household been diagnosed with a bleeding disorder?
*Please note family members living in separate households MUST complete their own registrations.  (Required.)

Yes

No

*4.Please indicate type of bleeding disorder:(Required.)

Hemophilia A/Factor 8

Hemophilia B/Factor 9

VWD

Carrier

Factor XII

Other (please specify)