Funding Form

Name:
Address (Inc State and Postcode):
Phone:
Email:
ELIGIBILITY:	I have a bleeding disorder I am a relative, carer/partner of a person with a bleeding disorder We do not require personal health information, however we need to be sure you are a person with a bleeding disorder, a relative or a carer, and therefore eligible to receive HFA funding – please tick relevant box and list a contact person at your Haemophilia Centre or local foundation for confirmation.
Name and contact details of someone at your Haemophilia Centre or your local Haemophilia Foundation for confirmation :
EXPECTED COSTS :	See registration form for full costs https://tinyurl.com/bdeneecm
Conference Registration $:
Accommodation $:
Flight/Transport Costs $:
Other Expenses - specify $:
TOTAL EXPECTED COSTS $:	Add above expenses
PERSONAL CONTRIBUTION $:	(What can you contribute towards the costs)
CONTRIBUTION FROM OTHER SOURCES $:	(State/territory haemophilia foundation funding, other sources)
TOTAL FUNDING REQUESTED $:
Have you attended a national haemophilia conference or international congress before?:	Yes No
If so, please specify :
Have you received HFA or local Foundation funding for a conference or congress before? :	Yes No
If so, please specify :
Please describe how you will benefit from attending the Conference and why you want to attend :
How will others benefit from your attendance? Who will benefit? :
Will you be attending the Conference with anyone else/will you be sharing costs? If so, please explain further:
Are you a current member of your local foundation? :
Any other comments or supporting information you would like to share (add another page if required) :