CHS-MC Member Registration

CHS-MC Member Registration

It is the mission of CHS-MC to, “improve the quality of life for those affected by hemophilia and other inherited bleeding disorders through support, service, research, education and advocacy.”
There is no fee to become a member.
Membership Categories: Please check the one that applies to you/your family
Members of CHS-MC are also members of the CHS, unless they choose not to be. Check below if you do not want CHS-MC to provide your name and address to the CHS.
Please read the Benefits of CHS-MC Membership and Confidentiality Statement.
Your approval is needed.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Email
example@example.com
Your Home Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
The Chapter uses a variety of outreach tools: social media, e-newsletter, email and the website. A new option is a text message service to contact you for the following: Meetings of the membership (AGM), product recalls, program notices and education sessions. Do we have your permission to add you to the text notification service?
About You
Your Name

First NameLast Name
Date of Birth: We ask for your date of birth to direct appropriate bleeding disorders information and education to you.
Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
Your Bleeding Disorder
- Family Member 1 Name
  
  First NameLast Name
- Family Member 1 Date of Birth: We ask for the date of birth to direct appropriate bleeding disorders information and education to your family.
- Family Member 1 Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
- Family Member 1 Bleeding Disorder
- Family Member 2
  
  First NameLast Name
- Family Member 2 Date of Birth: We ask for the date of birth to direct appropriate bleeding disorders information and education to your family.
  
  MonthDayYear
  Date
- Family Member 2 Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
- Family Member 2 Bleeding Disorder
- Family Member 3
  
  First NameLast Name
- Family Member 3 Date of Birth: We ask for the date of birth to direct appropriate bleeding disorders information and education to your family.
  
  MonthDayYear
  Date
- Family Member 3 Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
- Family Member 3 Bleeding Disorder
- Family Member 4
  
  First NameLast Name
- Family Member 4 Date of Birth: We ask for the date of birth to direct appropriate bleeding disorders information and education to your family.
  
  MonthDayYear
  Date
- Family Member 4 Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
- Family Member 4 Bleeding Disorder
- Family Member 5
  
  First NameLast Name
- Family Member 5 Date of Birth: We ask for the date of birth to direct appropriate bleeding disorders information and education to your family.
  
  MonthDayYear
  Date
- Family Member 5 Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
- Family Member 5 Bleeding Disorder
- Family Member 6
  
  First NameLast Name
- Family Member 6 Date of Birth: We ask for the date of birth to direct appropriate bleeding disorders information and education to your family.
  
  MonthDayYear
  Date
- Family Member 6 Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
- Family Member 6 Bleeding Disorder
- Family Member 7
  
  First NameLast Name
- Family Member 7 Date of Birth: We ask for the date of birth to direct appropriate bleeding disorders information and education to your family.
  
  MonthDayYear
  Date
- Family Member 7 Gender: We ask for your gender to direct appropriate bleeding disorders information and education to you.
- Family Member 7 Bleeding Disorder

CHS-MC Member Registration

There is no fee to become a member.

About You