Teen Retreat Registration

Meet other high school students with bleeding disorders, participate in interactive activities, and learn some valuable things about becoming more independent.

One hour meetings will be held monthly via Zoom starting on February 1, 2023
The first meeting will introduce you and your parents/guardians to the program
Discussion topics will be determined by the teens
A free mystery fun activity will be held in the fall
Program is free of charge
Requirements for participation:
- You must attend a Hemophilia Treatment Center (HTC) in Michigan, Indiana or Ohio
- You must be a 2022-23 freshman, sophomore, junior or senior in high school

Complete the registration below to get on the mailiing list for this program. This does not commit you to the program. It allows us to provide you more information about the program

Participant's Name*

First NameLast Name

Date of birth*

Phone Number*

E-mail*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Parent/Guardian Name*

First NameLast Name

Parent Email*

example@example.com

What grade will you be starting this fall in school?*

FreshmanSophomoreJuniorSenior

What are your plans after you graduate high school?*

CollegeTechnical school/tradeJoin the work force

Which HTC do you attend?*

Do you need assistance with internet connectivity?

YesNoMaybe

Are you interested in participating in the Bleadership program?

YesMaybe

Signature*

Parent Signature*

Bleadership Program