Become a Member

“The Bleeding Disorders Foundation of North Carolina (BDFNC) is important to me because they provide our family with valuable education and opportunities to engage with a community of others with bleeding disorders. Without BDFNC we wouldn’t know anyone else with a bleeding disorder.”

Membership is FREE! Extended family members, friends, and medical professionals are also welcome to join the BDFNC and receive our information.

Please complete the online membership form here so that we can connect with you about relevant programs and services.

Contact Information

First Name *

Last Name *

Suffix

Address *

Address Line 1

Address Line 2

City

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Phone - Home

Phone - Cell

Bleeding Disorders Information

Relationship to the Bleeding Disorder Community (check all that apply)

• I have a bleeding disorder
• Someone in my family has a bleeding disorder
• Friend
• Hospital/Medical Professional
• Industry
• Supporter
• Volunteer

Please select member of family with bleeding disorder:

• Child
• Spouse/Partner
• Mother
• Father
• Step Parent
• Sibling
• Grandparent
• Family (other)

Name of friend

Institution/Company

Company

Please Specify

Type of Bleeding Disorder (check all that apply)

• Hemophilia A (factor 8 deficiency)
• Hemophilia B (factor 9 deficiency )
• Von Willebrand disease
• Platelet Disorder
• Glanzman’s Thrombasthenia
• Factor 1 deficiency
• Factor 2 deficiency
• Factor 5 deficiency
• Factor 7 deficiency
• Factor 10 deficiency
• Factor 11 deficiency (hemophilia c)
• Factor 12 deficiency
• Factor 13 deficiency
• Carrier (not symptomatic)
• Symptomatic Carrier
• Other
• Don’t know
• Inhibitor

Please Select ( Hemophilia A (factor 8 deficiency) )

• mild
• moderate
• severe
• unknown

Please Select ( Hemophilia B (factor 9 deficiency ) )

• mild
• moderate
• severe
• unknown

Please Select ( Von Willebrand disease )

• type 1
• type 2a
• type 2b
• type 2m
• type 2n
• type 3

Name of platelet disorder

Please specify type of bleeding disorder if known

Select ( Inhibitor )

• Yes
• No
• Unsure
• NA

Date of Birth of Person with Bleeding Disorder

Family/Household Information

We have a variety of events throughout the year for different subsets of our community (example: siblings). Providing this information helps us provide relevant information based on your household. It also helps us better provide support for the entire family.

Adults in household

• Add

Name

Date of Birth

Gender

• Male
• Female

Prefer to Describe

Has a bleeding disorder

• Yes
• No

Add Another Adult Remove

Children in household

• Add

Children Name

Date of Birth

Gender

• Male
• Female

Prefer to describe

Has a bleeding disorder

• Yes
• No

Add Another Child Remove

Communication Preferences and Interests

Communication Preferences (check all that apply) *

• Email
• Printed Mailings
• Printed Newsletter
• Unsure
• Texts (occasional texts about upcoming events and important news)

How did you hear about the Bleeding Disorders Foundation of North Carolina? (check all that apply)

• Hemophilia Treatment Center
• Specialty Pharmacy or Homecare company
• Word of mouth
• Internet
• Medical ID
• Other

Please Specify

Program(s) of Interest (check all that apply)

• Blood Brotherhood (for men with a bleeding disorder)
• HOPE (for families with children with a bleeding disorder)
• SOAR (for women with a bleeding disorder)
• Teens
• Unión Latina (Programs in Spanish)
• Advocacy (use your voice to make a difference)

Check here if you are updating your contact information

• I am updating my contact information

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