Patients Sponsorship Programme Application

3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Limassol, Cyprus – 24 -26 October 2012

Please complete the form preferably electronically (or use capital letters for hand writing) and return to by Fax: +357-22-314552 by the 7 June 2012the latest.

All fields should be completed for the application to be valid.

Indicate which type of Sponsorship you are applying for:
A. Reimbursement of up to €500 after the conference upon receiving receipts. This will cover accommodation for a maximum of 3 nights, travel expenses & registration.
B. Full coverage of accommodation for 3 nights, registration and transfer from the airport.
APPLICANT’S CONTACT DETAILS
First name/s: / Surname:
Title (please √ where appropriate):
DrMr Mrs Ms / Gender:
Male / Female / Date of birth (dd/mm/yy):
______
Please √ where appropriate:
  1. Thalassaemia major patient
  2. Thalassaemia intermedia patient
  3. Sickle cell disease patient
  4. Other Please specify:______

Postal address: ______
______
______
______
Post code : ______City: ______Country : __ ______
Telephone (including all dialing codes): ______
Mobile: ______Fax: ______
Office phone: ______
Email address: ______
OTHER INFORMATION
The responses you give in each of the following sections will be used to assess your application form
Q1. What language(s) do you speak?
______
Q2. Will you be able to follow presentations in English?
Yes No
Q3. Have you been previously sponsored to attend a TIF event (seminar, workshop, conference)? If yes, please state which one(s)? (Include only the last four years)
1.
2.
3.
4.
5.
Q4. Please indicate the reasons why you want to participate in the 3rd Pan-European Conference on Haemoglobinopathies and Rare Anaemias and what your expectations are of this conference.
Emergency contact: Please supply the details of someone who can be an emergency contact for the period of the event.
Full Name ______
Relationship______
Tel. no. (including all dialing codes) ______
Fax (including all dialing codes) ______
Mobile / cell phone no. (including all dialing codes) ______
Office phone no. (including all dialing codes) ______
Email ______
DATE: ______

Please note that completion of the application form does not in any way guarantee funding from Thalassaemia International Federation or legally bind the Federation for reimbursement of any costs that may be incurred by the applicant during the processing of the application form.

Accompanying Documentsrequired (please attach):

  1. Letter from national thalassaemia association confirming that you are a member

Sponsorship Application Form_ 3rd Pan-European Conference_ October 2012 Page 1 of 2