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NRBDO Travel and Accommodation Subsidies Application for 2009 Conference

Progress in Comprehensive Care for Rare Blood Disorders

Delta Toronto Airport West, Mississauga, Ontario: November 13-15, 2009

The NRBDO is able to provide a limited number of subsidies of $1000 (maximum) to patient group representatives to help offset the cost of travel and accommodation to its 2009 conference. The subsidies are meant for those representatives who either themselves or whose own patient groups would not be able to fully support their participation. The applications will be reviewed and notification given shortly after the application deadline of October 5, 2009. Priority will be given to patients from NRBDO member organizations.

Successful applicants will be required to pay the conference registration fee. Registration fee includes breakfasts and lunches as well as all materials: $50 per day or $100 for the 3-day package.

Application Form

|1. Your contact details |

|First name |      |Last name |      |

|E-mail |      |Telephone |(     ) |      |

|Address |      |Postal code |      |

|City |      |Province |      |

|2. Your organization |

|Name |      |

|Disease Group represented: |      |

|E-mail |      |Web site |      |

|Telephone |(     ) |      |Fax |(     ) |      |

|Address |      |Postal code |      |

|City |      |Province |      |

|3. Your role in the patient organization |

|Are you? |Patient |Staff |

|Please check ( | | |

| |Parent of patient |Volunteer |

|How long have you been active in the organization? |      |

|What are your roles or activities? (100 words max) |      |

|Do you represent your organization on any policy advisory committees or |If so, please specify: |

|working groups? |      |

|YES: NO: | |

|4. Your experience/knowledge (100 words max.) |

|Please describe your experience or interest in advocating for your rare disorder or other issue. |

|      |

|5. Your expectations (100 words max.) |

|Please describe your expectations regarding this conference and how it will help you in your role within your patient group. |

|      |

|6. Your commitment |

|Please evaluate your level of commitment to be potentially involved as an advocate or representative in policy and procedures, to share knowledge and |

|exchange experience and to represent rare blood disorder patients at local, regional or national forums. |

| |

|If selected to attend the 2009 NRBDO Conference : |

|I agree to attend the full two-and-a-half day programme; |

|I agree to be included on a NRBDO list of potential volunteers so as to act as a rare blood disorder patient representative for activities related to |

|rare blood disorders. |

|Once my name is included on the NRBDO list, I agree to: |

|Share my knowledge; |

|Share my experience; |

|Be appointed as “expert patient” to participate in working groups or meetings, based on availability and appropriateness; |

|Participate in other conferences and workshops, based on availability and interest. |

|Signature:       |Date:       |

Please fill out this form and send it back along with your conference registration form no later than October 5, 2009.

By e-mail: nrbdo@hemophilia.ca By fax: 1-514-848-9661

By mail: Network of Rare Blood Disorders (NRBDO)

c/o Canadian Hemophilia Society

625 President-Kennedy Avenue, Suite 505

Montreal, Quebec H3A 1K2

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