NATIONAL PATRON
The Right Honourable Sir Ninian Stephen, KG, AK, GCMG, GCVO, KBE
STATE PATRONS
AUSTRALIAN CAPITAL TERRITORY Dr Richard G Pembrey, AM, MBBS, MD, FRACP, FRCPA
WESTERN AUSTRALIA Her Excellency the Honourable Kerry Sanderson, AO, Governor of Western Australia
NEW SOUTH WALES Dr. Kevin A Rickard, AM, RFD
VICTORIA Dr Alison Street, AO
TASMANIA Lady Green
QUEENSLAND His Excellency The Honourable Mr Paul de Jersey, AC, Governor of Queensland
President: Gavin Finkelstein
Executive Director: Sharon Caris
HAEMOPHILIA FOUNDATION AUSTRALIA
LIMITED FUNDING AVAILABLE FOR NATIONAL CONFERENCE 2017
The 18th Australian & New Zealand Conference on Haemophilia & Rare Bleeding Disorders will be held at
Pullman Albert Park Melbourne from 12-14 October 2017.
For information about the conference, registration and accommodation costs visit
http://www.haemophilia.org.au/conferences.
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HFA has allocated $15,000 to assist people living with a bleeding disorder, relatives/partners or
carers to attend the Conference
Part funding will be favoured over full funding to increase access to more people
You will generally be expected to contribute towards your costs
Please advise if you are requesting or have received funding from other sources
Applications will be assessed on their merit – it is in your interests to provide full responses to the
questions on the application form.
Applications to HFA for funding close Friday 29 July 2017.
Other funding options may be available from your local haemophilia foundation.
For further information regarding funding contact Sharon Caris e:[email protected]
p:1800 807 173.
MEMBER ORGANISATIONS - HAEMOPHILIA FOUNDATIONS: • AUSTRALIAN CAPITAL TERRITORY • NEW SOUTH WALES • QUEENSLAND • TASMANIA • VICTORIA • WESTERN AUSTRALIA
• NATIONAL MEMBER ORGANISATION OF THE WORLD FEDERATION OF HEMOPHILIA
7 DENE AVENUE MALVERN EAST VICTORIA AUSTRALIA 3145 TELEPHONE: (03) 9885 7800 FACSIMILE: (03) 9885 1800
EMAIL: [email protected] WEBSITE: www.haemophilia.org.au
Donations over $2 are tax Deductible
Registered as Haemophilia Foundation Australia Incorporated, No. A0012245M. ABN 89 443 537 189
APPLICATION FORM 2017
Name:
Address:
Telephone:
Mobile:
Email:
ELIGIBILITY: We do not require personal health information, however we need to be sure you are eligible
to receive HFA funding – please tick relevant box and list a contact person at your Haemophilia Centre for
confirmation.
I have a bleeding disorder
I am a relative, carer/partner of a person with a bleeding disorder
Contact person at your Haemophilia Centre for confirmation
EXPECTED COSTS
Item
$
Conference Registration
Accommodation
Flight/Transport Costs
Other Expenses - specify
TOTAL EXPECTED COSTS
PERSONAL CONTRIBUTION
(What can you contribute towards the costs)
CONTRIBUTION FROM OTHER SOURCES
(State/territory haemophilia foundation funding, other sources)
TOTAL FUNDING REQUESTED
Have you attended a national haemophilia conference or international congress before?
If so, please specify
Have you received HFA or local Foundation funding for a conference or congress before?
If so, please specify
YES
YES
NO
NO
Please describe how you will benefit from attending the Conference and why you want to attend
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How will others benefit from your attendance? Who will benefit?
Will you be attending the Conference with anyone else/will you be sharing costs?
If so, please specify
Any other comments or supporting information you would like to share (add another page if required)
Signed:
Date:
Return the form to 7 Dene Avenue, Malvern East Vic 3145 or email [email protected] by Friday
29 July 2017.
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