National Hemophilia Foundation > 57th Annual Meeting

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NHF > Events > Annual Meeting

NHF NATIONAL YOUTH LEADERSHIP INSTITUTE

APPLICATION: FOR YOUNG ADULT DELEGATE TO COMPLETE

Please submit this form no later than July 31, 2005.

If you are under 18 years of age, you must have your parent/guardian fill out the required parent/guardian fields. Your application will be considered incomplete otherwise.

First Name:
Last Name:
Age:
Address:
City:
State:
Zip:
Home Telephone: (xxx-xxx-xxxx)
Work or College Dorm Telephone (if applicable): (xxx-xxx-xxxx)
E-mail:
Best Time to Contact:	AM PM
Affilitation to Hemophilia/Bleeding Disorders Community (i.e. Do you, a family member, or friend have a bleeding disorder):
My Local Chapter/Association is:
My Hemophilia Treatment Center is:
Do you have any personal or business relationships or circumstances that you believe could contribute to a conflict of interest as defined in the National Hemophilia Foundation's Volunteeer Code of Conduct	Yes No If yes, please explain:
Current School:
Have you been accepted to a college or technical school:	Yes No
Where:
Please complete if applicant is younger than 18 years of age.
Name of Parent/Guardian
As a parent/guardian, I agree to attend and room with my son/daughter at the NHF Annual Meeting and will be responsible for providing any supervision as needed. I agree
Please list all activities that you have been involved in for the last four years. Please include dates if possible.
School Organizations:

Athletics:

Awards, Honors, Achievements:

Volunteer Work/Community Service (Please also include work pertaining to bleeding disorders):

Please respond to the following essay question in 250 words or less: Please discuss a past leadership experience and explain how you can use this experience to benefit the bleeding disorders community.