*  Email Address: *  First Name: *  Last Name: *  Address: Address (line 2): Apartment *  City: *  State: --United States-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming --Canada-- Alberta British Columbia Manitoba New Brunswick Newfoundland North West Territory Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Not Applicable *  Zip Code: *  Home Phone: Mobile Phone: Gender: Not Applicable Male Female Date of Birth (enter as MM/DD/YYYY): Tell us which best describes you (choose one): person with hemophilia, person with VWD, parent or guardian, relative, clinician, industry, other: Significant Other's First Name (if applicable): Significant Other's Last Name: Significant Other's Date of Birth (enter as MM/DD/YYYY): If you use a hemophilia treatment center (HTC), please tell us which one: If you do not use an HTC, please tell us the name of your hematologist: Please tell us your primary language if it is not English: How did you hear about NYCHC: Additional Family Member 1 (enter first name only unless last name is different): Additional Family Member 1 Date of Birth (enter as MM/DD/YYYY): Additional Family Member 2 (enter first name only unless last name is different): Additional Family Member 2 Date of Birth (enter as MM/DD/YYYY): Additional Family Member 3 (enter first name only unless last name is different): Additional Family Member 3 Date of Birth (enter as MM/DD/YYYY): Additional Family Member 4 (enter first name only unless last name is different): Additional Family Member 4 Date of Birth (enter as MM/DD/YYYY): Please add any additional family member names and birthdates here: Please tell us which individuals in your family have a bleeding disorder: Please tell us if any of your family members have an inhibitor. *  Enter the letters shown above:

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