Contact Form : Get Involved : National Bleeding Disorders Foundation

By completing the form below, you authorize the West Virginia Chapter of the National Bleeding Disorders Foundation to add the information provided to our mail and email correspondence lists. WVNBDF will then contact you by phone in order to obtain any additional information that may be relevant for determining program interest and eligibility. Your participation is completely voluntary and can be withdrawn at any time upon your request. Your information will not be used for any other purpose or released to any other parties.

Household Information:

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Email (Required)

Phone (Required)

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I would like to be contacted by the chapter regarding education and community events

I would like to be contacted to volunteer

Patient Diagnosis:

Hemophilia A (Factor VIII Deficiency)
Hemophilia B (Factor IX Deficiency)
VwD (Von Willebrand's Disease)
Carrier
Factor VII Deficiency
Factor XIII Deficiency
Other rare bleeding disorder
Provider (Hematologist, Nurse, Social Worker, Physical Therapist, Dentist)

WVNBDF measures it's success by its programs. Please indicate your FAMILIE'S areas of interest:

Advocacy
Board of Directors
Youth Camp (Ages 7-17)
Family Camp
Unite for Bleeding Disorders Walk
Annual Education Meeting
Other Programs

Family Member Information:

Indicate individuals name, DOB, status (Affected, caregiver, sibling, etc.), bleeding disorder type, and severity: (Required)

Please list all members of your household so we can best serve your families needs!

Welcome to the West Virginia Hemophilia Foundation Community!

WVNBDF provides programming, education, assistance, support, and resources for individuals and families that are affected by genetic and chronic bleeding disorders. Our vision is to create an environment where you feel part of a community, part of the solution, and empowered in your daily life through connection with others who can relate to you and your challenges. The chapter provides free opportunities throughout West Virginia and the United States to create connections and allow a comprehensive understanding of available resources. Your participation is the most valuable part of our organization.

We would also invite you to Like our Facebook page where we provide lots of updates about our events and other activities.

NBDF West Virginia Consent to Contact Form

Household Information:

Family Member Information:

Welcome to the West Virginia Hemophilia Foundation Community!

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