Wellness Initiative Application

Application for Wellness Support

The Greater Ohio Bleeding Disorders Foundation (GOBDF) offers wellness assistance up to $250 per person with an eligible (factor deficient) bleeding disorder. For households with multiple patients, there is a household max of $400.

Examples of initiatives funded include swimming lessons, yoga studio memberships, golf instruction, and dance lessons. We also contract with a virtual yoga instructor who provides live and recorded sessions to the community at no charge to the patient.

Please provide all information necessary for us to pay the vendor below. Failure to do so may result in a delay in approval and processing. Direct reimbursements are discouraged and cannot be guaranteed without prior approval from GOBDF staff.

Please contact your HTC social worker or tracy@gobdf.org with any questsions.
Name

First NameLast Name
Age*
Type of Bleeding Disorder*
Hemophilia Treatment Center where the patient is seen*

Ohio State UniversityNationwide Children's HospitalUniversity Hospitals Cleveland Medical CenterAkron Children's HospitalOther
If "other" please enter where patient is seen
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email*
example@example.com
Name of Wellness Center/Provider*
Office phone number of Wellness Center/Provider*
Please enter a valid phone number.
Address of Wellness Center/Provider (please ensure that this is the correct address for receiving payments)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill or invoice*

Cancelof
Notes/Comments/Special Requests
I give my HTC or treating hospital permission to confirm my/my family members' bleeding disorder diagnosis with chapter staff.

Yes (Required to attend programs and receive services)No
Should be Empty: