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APPLY NOW

Application Deadline : February 10th, 2020

Personal Information

  • Please use your name as it appears in your Passport in filling out this application
  • Please be sure you have an email that is working, you are checking regularly and is easily able to identify you (no nick names or letters that can confuse the Application Reviewer as to who you are in your email address). If needed create a new email that identifies you by your name.

Before Applying:

Check to ensure you meet all the criteria listed. Include the following pieces of your application.  An incomplete application will not be considered:

  • A letter of diagnosis from your medical team (physician or nurse), stating what your bleeding diagnosis is and on average how often in a year you treat for bleeding episodes excluding Stimate/Amicar and or iron replacement.
  • One letter of support from your local foundation, chapter or association.
  • One letter of support from a person who can attest to your ability to attend the Step Up Reach Out Program, not a family member.
  • A personal essay, explaining in your own words your interest in joining Step Up Reach Out – at least 500 words.
  • The ability to bring factor concentrate or your product for treatment with you.  There are no exceptions!

SURO Applicant Criteria:

To be considered for this program, you must meet the following requirements: Diagnosed with a bleeding disorder which will include:

  • Hemophilia A & B all severities
  • Between the ages of 21 and 25 (no exceptions)
  • Able to self-infuse your factor concentrate and have access to factor for the duration of conference dates (no factor or infusion assistance can be provided during the program)
  • Proficient in written and spoken English (no exceptions)
  • Able to attend all program sessions
  • Able to travel unaccompanied and with appropriate visa and/or passport
  • Have access to factor concentrate or your treating medication to bring to the program meetings
  • Able to fulfill all aspects of the program criteria and understand what is being asked of you.

Can’t Complete the Application Online?

We encourage applicants to fill out our online application. If you cannot fill out the online application, you may download a PDF of the SURO application here. Submit it, along with your Letters of Support, Letter of Diagnosis and Personal Essay via:

SECTION 1: PERSONAL INFORMATION

SECTION 2: EMERGENCY CONTACTS

SECTION 3: MEDICAL INFORMATION

How long have you attended this treatment center?
Do you have limited mobility or require any special services? *
YesNo
SECTION 4: TRAVEL INFORMATION

Do you have a valid passport? *
YesNo
SECTION 5: ADDITIONAL INFORMATION REQUIRED TO PROCESS YOUR APPLICATION
Before Applying:


*At least one letter of reference from a teacher, care provider, employer or others able to recommend your participation.

*One letter of support from your local foundation, association or chapter.
SECTION 6: RELEASE OF INFORMATION/LIKENESS AND CONTACT INFORMATION

I understand I must have factor concentrate available for me to bring to the SURO Program Meetings in the event of a bleed and/or emergency.
I understand failure to bring factor concentrate or my treating medication with me to the SURO Program Meetings will be caused to be dismissed from the program.
By submitting your application, you grant permission for any photographs or video taken of you during the Step Up Reach Out sessions and activities, and any that you may take related to program activities, to be used in publications or pamphlets for further promotion of the Global Blood Disorder Foundation Inc. and Global Blood Disorder Foundation Program Faculty. You are also aware of needing to have your factor concentrate or treating medication with you at the program meetings and the consequences if you do not.
SECTION 7: DISCLAIMER OF ACCEPTANCE