Nevada Chapter, NBDF
7500 W. Lake Mead Blvd
Suite 9 #458
Las Vegas, NV 89128

Technology Assistance Application

BASIC INFORMATION
First Name *
Middle
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Phone
Where you can be reached for follow up questions
Email
Number of people living in the household?
Name(s) of household members with bleeding disorders and type of bleeding disorder
Please select what assistance you are requesting
Please select what assistance you are requesting
Please describe your need for technology assistance
Use as much detail as possible
Please describe how technology assistance will help resolve the current need
Include as much detail as possible
Please check the following the indicate your understanding and commitment:
Please check the following the indicate your understanding and commitment:
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

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.

Nevada Chapter, NBDF
7500 W. Lake Mead Blvd
Suite 9 #458
Las Vegas, NV 89128

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