Standard Registration Form Questions

• Please select your NBDF Chapter Affiliation (dropdown menu)

• Primary Community Member Description & Additional Community Member Descriptions

  • Person with a bleeding disorder

  •  Family Member/Friend of a person with a bleeding disorder

  •  NBDF Board Member

  •  NBDF Affiliated Chapter Board Member/Volunteer

  •  NBDF Affiliated Chapter Staff

  •  Unaffiliated Organization Staff 

  • Unaffiliated Organization Volunteer

  • Government Staff

  • Provider: Physician

  • Provider: Physician Assistant

  • Provider: Researcher/Scientist

  • Provider: Nurse

  • Provider: Nurse Practitioner

  • Provider: Research Nurse

  • Provider: Pharmacist

  • Provider: Physical Therapist

  • Provider: Social Worker/Psychologist

  • Provider: Genetic Counselor

  • Pharmaceutical/Biotech Company Staff

  • Specialty Pharmacy Staff

  • Home Healthcare Staff

  • Medical Student

  • Non-Profit Employee

  • Other (Please describe) 

• HTC Affiliation (dropdown menu)

• Type of Bleeding Disorder

  • Factor I Deficiency

  • Factor II Deficiency

  • Factor V Deficiency

  • Factor VII Deficiency

  • Factor VII Deficiency (Hemophilia A)

  • Factor VIII Deficiency (Hemophilia B)

  • Factor X Deficiency

  • Factor XI Deficiency

  • Factor XII Deficiency

  • Factor XIII Deficiency

  • Hemophilia with Inhibitor

  • Carrier

  • VWD

  • Other Bleeding Disorder

  • N/A

• Are you employed in the field of bleeding disorders?

• Racial/Ethnic Background

  • Alaska Native or American Indian

  • Asian or Asian American

  • Black or African American

  • Hispanic or Latino

  • Native Hawaiian or Other Pacific Islander

  • White

  • Other/Multi Ethnic

• Gender

  • Man (Boy for children registration)

  • Woman (Girl for children registration)

  • Prefer to describe

  • Prefer not to disclose

• Preferred Pronouns

  • She, Her, Hers

  • He, Him, His

  • They, Them, Theirs

  • Ze, Zir, Zirs

  • Xe, Xem, Xyrself

  • Ze, Hir, Hirs

  • Per Per, Pers

  • Prefer to describe

  • Prefer not to disclose

• Age Range

  • 0 - 12 years

  • 13 - 17 years

  • 18 - 20 years

  • 21 - 35 years

  • 36 - 45 years

  • 46 - 55 years

  • 56 - 65 years

  • 66 years and older

• Do you speak any language aside from English?

For In-Person meetings only:

• Please indicate your dietary restrictions (check all that apply)

  • Vegetarian

  • Vegan

  • Peanut Allergy

  • Shellfish Allergy

  • Treenut Allergy

  • Lactose Intolerant

  • Celiac Disease (Gluten free)

  • Pescatarian

  • Other

  • If other, please specify:

• Will you be needing any of the following services during the conference?

  • Scooter

  • Wheelchair

Hotel Questions (if applicable):

• Full Name (as listed on government-issued ID)
• Check-in date
• Check-out date
• Bed Preference (King/Doubles/ADA) *Not guaranteed unless ADA is requested
• Room Floor Preference (high/low) *Not guaranteed
• Hotel Loyalty Membership Number
• Additional Comments/Requests