It is with much regret that we announce that the NOW Conference is postponed until further notice due recommendations from the CDC to prevent the spread of the novel coronavirus (COVID-19). 

The safety and well-being of everyone that supports this conference is of highest priority to us. 

We stand strong as a community to support and protect our friends, family and greater public community.


REGISTRATION IS FULL, PLEASE COMPLETE THE APPLICATION TO BE PLACED ON THE WAIT LIST


NOW May 29-31, 2020 Application Form



A refundable deposit of $50 for an individual or $100 per family will be collected if you are selected to attend the conference.  A deposit will only be collected if you have been selected to attend the conference. If your application is selected, we will notify you via email. Failure to respond in a timely manner could jeopardize your acceptance to the conference.

 
This form serves as the application for the May 29-31, 2020 conference. The conference will be held in Phoenix, AZ. The costs of travel, hotel room, and meals from Friday evening through end of conference Sunday are covered by the sponsors.

 
BY SUBMITTING THIS APPLICATION, YOU AGREE THAT ALL INFORMATION PROVIDED IS TRUE AND ACCURATE. FALSIFYING INFORMATION ON THIS APPLICATION WILL RESULT IN IMMEDIATE DISQUALIFICATION. 
* Required Fields
NOW Main Applicant Information (Head of Household)
* First AND Middle Names as they appear on your License or ID 
* Gender 
* Last Name as it appears on your License or ID 
* Date of Birth (mm/dd/yyyy) 
* Cell Phone 
* Address 
* City 
* State 
* Zip 
* Email 
* Enter your name
as you'd like it to
appear on a
name tag 
  Please list any special medical needs you or your family has. 
  Have you attended a previous NOW Conference?
Required, Check all that apply. 
  2012   2013   2014 
  2015   2016   2017 
  2018   2019   I have never attended 
* Are you or any family members affiliated with any bleeding disorder industry partners? (Manufacturer, Specialty Pharmacy, etc.) 
  If yes, please explain * T-Shirt Size 


NOW Applicant Medical Information
* Do you have von Willebrand Disease? 
  Date of diagnosis? 
  Type/Severity Level? 
  Do you or any of your family members take any medications for VWD? 
* Name of Hematologist for the affected family member(s)? 
* What do you and your family hope to gain from attending the NOW conference? 
  Please Note: We cannot guarantee that the event facility can accommodate food allergens and it is the sole responsibility of the attendee to ensure they make proper arrangements for meals. 


NOW Travel Arrangements
* Airport Departure City 
  Please list any special travel information and/or needs your family has. 
  If selected to attend, do you wish to book your own flight and be reimbursed per conference guidelines? Reimbursements are given at the conference.(check box for yes) 


Your Local Chapter
* What is the name of your local chapter? 
* State of Local Chapter 
* Local Chapter Phone Number 


Photo Release
  From time to time, Arizona Bleeding Disorders will want to use pictures, voice and video from the NOW Conference to promote the conference and Arizona Bleeding Disorders activities. While names will never be used, we would like permission to be able to use your image and/or voice for that purpose. I give my permission to use my image or voice in print, podcast, or video. 
*  


Additional Family Members
  If you have additional family members (i.e. spouse, children living in the same household) attending, you must complete all of the following fields for each family member for them to be considered part of your application. Failure to complete each field may result in denial of additional family members. If you have more family members than the form allows, submit this application, then email Vickie at [email protected]. 
* Total number of family members attending (including yourself) 
* How many people in your immediate family are diagnosed with VWD? 


First Additional Family Member
  FULL Legal Name
(As it appears on your ID
First Middle Last) 		  Enter the name as you'd like it to appear on a name tag (13+) 
  Date of Birth (mm/dd/yyyy) 
  Gender 
  Does this applicant have vWD?    Date Diagnosed? 
  Type/Severity Level?   Relationship to main applicant? (Child, Spouse) 
  Does this family member have any special needs (allergies? special needs in childcare? etc.)**We cannot guarantee that the event facility can accommodate food allergens and it is the sole responsibility of the attendee to ensure they make proper arrangements for meals.**   Has this family member attended a past NOW Conference? 
  T-Shirt Size 


Second Additional Family Member
  FULL Legal Name
(As it appears on your ID
First Middle Last) 		  Enter the name as you'd like it to appear on a name tag (13+) 
  Date of Birth (mm/dd/yyyy) 
  Gender 
  Does this applicant have vWD?    Date Diagnosed? 
  Type/Severity Level?   Relationship to main applicant? (Child, Spouse) 
  Does this family member have any special needs (allergies? special needs in childcare? etc.)**We cannot guarantee that the event facility can accommodate food allergens and it is the sole responsibility of the attendee to ensure they make proper arrangements for meals.**   Has this family member attended a past NOW Conference? 
  T-Shirt Size 


Third Additional Family Member
  FULL Legal Name
(As it appears on your ID
First Middle Last) 		  Enter the name as you'd like it to appear on a name tag (13+) 
  Date of Birth (mm/dd/yyyy) 
  Gender 
  Does this applicant have vWD?    Date Diagnosed? 
  Type/Severity Level?   Relationship to main applicant? (Child, Spouse) 
  Does this family member have any special needs (allergies? special needs in childcare? etc.)**We cannot guarantee that the event facility can accommodate food allergens and it is the sole responsibility of the attendee to ensure they make proper arrangements for meals.**   Has this family member attended a past NOW Conference? 
  T-Shirt Size 


Fourth Additional Family Member
  FULL Legal Name
(As it appears on your ID
First Middle Last) 		  Enter the name as you'd like it to appear on a name tag (13+) 
  Date of Birth (mm/dd/yyyy) 
  Gender 
  Does this applicant have vWD?    Date Diagnosed? 
  Type/Severity Level?   Relationship to main applicant? (Child, Spouse) 
  Does this family member have any special needs (allergies? special needs in childcare? etc.)**We cannot guarantee that the event facility can accommodate food allergens and it is the sole responsibility of the attendee to ensure they make proper arrangements for meals.**   Has this family member attended a past NOW Conference? 
  T-Shirt Size 


Fifth Additional Family Member
  FULL Legal Name
(As it appears on your ID
First Middle Last) 		  Enter the name as you'd like it to appear on a name tag (13+) 
  Date of Birth (mm/dd/yyyy) 
  Gender 
  Does this applicant have vWD?    Date Diagnosed? 
  Type/Severity Level?   Relationship to main applicant? (Child, Spouse) 
  Does this family member have any special needs (allergies? special needs in childcare? etc.)**We cannot guarantee that the event facility can accommodate food allergens and it is the sole responsibility of the attendee to ensure they make proper arrangements for meals.**   Has this family member attended a past NOW Conference? 
  T-Shirt Size 




 
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