CSL Behring Junior National Championship
HFM Participation Application
Invitation and Information:
We are very excited to have the opportunity to send two representatives of the Hemophilia Foundation of Maryland to the CSL Behring Getting in the Game Junior National Championship (JNC). Each participant will have the opportunity to choose either baseball, basketball, golf or swimming for this year's JNC. CSL Behring will provide travel arrangements and cover travel costs, including airfare, hotel accommodations, scheduled meals and transportation while in the host city for each competitor and one accompanying adult.(Please note: family will be responsible for their own transportation to and from their hometown airport.) During the program, educational sessions will be available for parents and caregivers, while participants will have the opportunity to take part in a clinic where they enhance the fundamentals of the sport, learn about the importance of physical activity, and show off their baseball or golf abilities in a national competition with fellow participants from around the country. To Be Eligible, all applicants must: (1) Be between the ages of 7 and 18 as of September 19, 2024 (2) Be a resident of Maryland (3) Have a Bleeding Disorder (4) Have some experience in golf, baseball, basketball or swimming (no need to be an expert! - just some basic knowledge). (5) Be able to attend the national JNC event in Henderson, NV on September 20-22, 2024. The deadline for submitting the application and essay is JULY 1, 2024. After the submissions are received, HFM will select eight semifinalists, (2) for baseball, (2) for golf, (2) for swimming and (2) for basketball. Two winners will be selected through a random drawing. As with any activity, CSL Behring and HFM encourage individuals to speak with their healthcare professional before engaging in any type of physical activity.
Child's Name:
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Type of Bleeding Disorder
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Severe Hemophilia A
Moderate Hemophilia A
Mild Hemophilia A
Severe Hemophilia B
Moderate Hemophilia B
Mild Hemophilia B
von Willebrand Disorder Type 1
von Willebrand Disorder Type 2
von Willebrand Disorder Type 3
Platelet Disorder
Other
Hemophilia Treatment Center Where Child Receives Care:
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Johns Hopkins Hemophilia Treatment Center
Children's National Medical Center
Georgetown
Christiana
Dupont
Private Hematologist
Other
Date of Birth: (must be between the age of 7 and 18 as of 9/19/2024)
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Month
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Day
Year
Date
Full Name of Parent/Guardian who is applying to attend JNC with their child:
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First Name
Last Name
Parent/Guardian's Date of Birth:
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Month
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Day
Year
Date
Sport Child is Interested in:
Basketball
Swimming
Baseball
Golf
Please state why you believe you would be a good representative of the Hemophilia Foundation of Maryland at the 2024 Junior National Championship. Parents/guardians may assist younger children, but the essay should be in the child’s own words)
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Waiver/Release of Information
I hereby declare that all the information provided in my application to the Hemophilia Foundation of Maryland is true, accurate, and complete to the best of my knowledge. I understand that any false statements, misrepresentations, or omissions may result in the rejection of my application. I authorize the Hemophilia Foundation of Maryland to contact my medical provider named in the application to verify the diagnosis of my bleeding disorder. I understand that this information will only be used for the purpose of verifying my eligibility. I have read and understand the terms of this waiver and release of information.
Parent Signature:
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If Child is 18, Child's signature is required:
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Date:
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Month
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Day
Year
Date
Submit
Should be Empty: