Stay In Motion APPLICATION Participant Information Eligible persons include: individuals diagnosed with a bleeding disorder and living in one of the 26 counties of Western PA or treated at the Hemophilia Center of Western PA; parents living in the same household as an individual with the diagnosed bleeding disorder; or friend or family member of the parent or person diagnosed with a bleeding disorder who is enrolled in the program; and are at least 13 years old. Question Title * 1. Participant Contact Information Name Address City/Town State/Province -- select 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/Postal Code Email Address Phone Number Question Title * 2. Enter your date of birth in the following format: MM/DD/YYYY Question Title * 3. What is your preferred method of communication Phone Call Text Message Email US Mail Question Title * 4. Do you have a bleeding diagnosis? Yes No Next
