Technology Assistance Application : Support & Resources : National Bleeding Disorders Foundation

BASIC INFORMATION

Head of Household First and Last Name

First Name *

Middle

Last Name *

Shipping Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Phone

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Phone (Required)

Where you can be reached for follow up questions

Email

Email (Required)

Number of people living in the household?

Number of people living in the household (Required)

Name(s) of household members with bleeding disorders and type of bleeding disorder

Name(s) of household members with bleeding disorders and type of bleeding disorder (Required)

Please select what assistance you are requesting

Tablet
Mifi with Internet

Please describe your need for technology assistance

Please describe your need for technology assistance (Required)

Use as much detail as possible

Please describe how technology assistance will help resolve the current need

Please describe how technology assistance will help resolve the current need (Required)

Include as much detail as possible

Please check the following the indicate your understanding and commitment:

1- If approved, I understand that my household will be issued a device for a six-month loan period and I am required to return the device(s) at the end of the six months
2- If approved, I understand that my household is required to attend a minimum of two virtual programs during the six-month loan period
3- I understand that as head of the household, if approved I will be responsible for the device(s) and may be financially responsible if they are not returned at the end of the six-month period
4- I commit to contacting the NHFNV office immediately if there is a problem or malfunction with the device
5- I certify that the information I have submitted is true and accurate to the best of my knowledge

Completion of this application will automatically register you with the Nevada Chapter of the National Hemophilia Foundation and place you on the mailing list. If you do not wish to be placed on the mailing list

Please read and initial (Required)

CONFIDENTIALITY

Information from the Nevada Chapter of NHF's Technology Assistance applications may be compiled for statistical purposes and for compliance with local, state, federal or affiliate organization requirements. However, any publication of this data will be in aggregate form only and will not include names or any other information that could be used to identify individual applicants or recipients.

Applicants and information pertaining to funding requests are considered confidential to the full extent permitted by law. All Nevada Chapter of NHF Advisory Board/Emergency Assistance Committee members are required to sign a confidentiality agreement.

No personal information will be used or disclosed for any purposes other than that for which it was collected without applicants' written permission. At no time will personal information be shared with any individual, company, and organization outside the Nevada Chapter of the National Hemophilia Foundation.

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