LadyBugs Virtual 2023 Registration

January 26th, 2023 - 🐞Opening Night! Join us on the 26th for a fun meet and greet and a sneak peak of SHEmophilia™️ to kick off the New Year 🎉
February 23rd, 2023 - Bleeding Disorder Breakouts🩸(vWD, Hemophilia, & RBD)
March 23rd, 2023 - Reproductive Health ♀👩‍⚕️
April 27th, 2022 - Rebuilding the Body with Diet 🥗 joined by Medexus

Applicants must be women who are diagnosed with a clotting factor/platelet deficiency, care for someone, or carry any bleeding disorder. Age requirements are lifted for the virtual format, but we recommend 16+ due to sensitive content in some of the sessions.

This form must be completed in one sitting - data will not be saved for a later completion. Sessions are for affected patients and caregivers only.

Estimated completion time: 7-10 minutes

Name of attending adult patient*

First Name Last Name

Email*

Confirmation Email example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Date of Birth*

Date

What best describes you? Check all that apply*

I have/deal with a bleeding disorderI care for someone with a bleeding disorderI am a carrier of a bleeding disorder WITH symptomsI am a carrier of a bleeding disorder WITHOUT symptoms

What type of bleeding disorder do you have?*

Bleeding Condition of Person I care for*

Severity*

Additional Diagnosis?

Use this field if you have a dual bleeding disorder diagnosis

What medication(s) are used to treat bleeds?*

Hematologist (or other Specialist)*

First Name Last Name

Phone Number for Specialist*

Please enter a valid phone number.

Name of HTC or other Medical Facility*

How did you hear about this program? (check all that apply)*

Confidentiality Agreement

CHES Foundation (a non-profit organized and existing out of the State of Massachusetts and all of its affiliates used to facilitate the program) shall be referred to in this agreement as “CHES”. I, (Participant) acknowledge and agree by signing and initialing that:

I have come to LadyBugs to learn and to share information about bleeding disorders, and in that spirit, I recognize that there may be discussions that are personal in nature (e.g., specifics relating to a patient’s condition). I will keep anything that I hear confidential and will not discuss it outside of the meeting.

If, along with being a person with a bleeding disorder, caregiver, family member, or healthcare provider I have a commercial interest in the supply of products (e.g., am employed by a home care company or similar organization) or services related to patient care, I agree to:

Respect the confidentiality of the consumer participants and will not promote my company’s/organization’s products or services now or in the future. My relationships will be strictly as consumer to consumer.

I will not steer conversation in the direction of bleeding disorders business. If I am asked directly about my company’s products or services,

I will state that this educational event is not the place for me to discuss any commercial interest and will notify CHES staff immediately about this inquiry.

In attending this meeting, I recognize that information regarding my disease-state may be made available to other participants. This information will not be used in a commercial manner by CHES (or their agents) without my expressed permission.

I understand I may be asked to cease from participation of LadyBugs if I do not honor the Confidentiality Statement in its entirety.

Release of Images

I hereby authorize representatives of CHES to photograph, or video record images of all accompanying family members and myself.

I also agree that the program and persons may use, and permit other persons to use the negatives, prints, digital photos, or video prepared in such a manner as either may deem appropriate. I grant CHES the absolute right and permission to copyright and/or use pictures of us in which they may be included in whole or in part, in advertising, business, or trade or any other lawful purpose whatsoever including publication to the CHES and/or websites and marketing materials.

I have entered into this agreement willfully and hereby waive any right to compensation for such uses by reason of the foregoing authorizations, and I hereby hold CHES harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.

The term "photograph" as used in the foregoing agreement, shall mean motion picture or still photography in any format, as well as videotape, videodisc and any other mechanical means of recording and reproducing images.

By signing below, I agree to all statements made in the Confidentiality Agreement and Release of Images*

Clear

Virtual LadyBugs - Winter/Spring 2023 Registration

Medical Information