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Washington Days Application
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1.
Name (First and Last)
(Required.)
*
2.
Address
(Required.)
*
3.
Email
(Required.)
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4.
Phone Number
(Required.)
*
5.
Select all that apply
(Required.)
Unaffected advocate for persons with a bleeding disorder
Parent/guardian of a minor child with a bleeding disorder
Person with a bleeding disorder
Please specify what bleeding disorder that you have
*
6.
Total number requesting to attend Washington Days
(Required.)
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7.
Select the Washington Days assistance you are requesting from the Nebraska Chapter.
(Required.)
Airfare
Lodging
Meal Assistance (Most meals are provided in Washington Days Registration)
Ground Transportation
All of the above
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8.
Describe why attending Washington Days is important to you (include as much detail as possible)
(Required.)