Sickle Cell Registration for Backpack and COVID 19 Supplies GIVEWAY

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* 1. Client Name

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* 2. Parent or Guardian Name (If under 18)

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* 3. Email Address:

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* 4. Age Range

Under 18

18-24

25-34

35-50

51-70

70+

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* 5. What is your race or ethnicity?

Black /African American

White

American Indian or Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

Self-describe below:

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* 6. Hemoglobin Type

Beta Thalassemia Zero

Beta Thalassemia Plus

No Sure

NO, I have Sickle Cell Trait

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* 7. Do you have a primary care provider

Yes

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* 8. Do you have a hematologist?

Yes

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* 9. Are interesting in attending a presentation about sickle cell disease and sickle cell trait?

Yes

Thank you for completing the registration. None of your personal information will be shared only the demographic data. This event is being sponsored by grant funds and community partners, and they are requiring demographic information only. Once again Sickle Cell Disease Association of Broward County, Inc. thanks you for taking the time to complete the registration form. When you click the DONE button your name will be automatically added to the list for the backpack and COVID-19 Essentials giveaway on Saturday, September 12, 2020, 10:00 am - 1:00 pm at the Westside Gazette 545 NW 7th Terrace, Fort Lauderdale, FL 33311

Due to COVID-19
We will be adhering to all social distancing rules. No walk ups allowed. As you pull up in your vehicle (please do not get out of your vehicle), open your trunk and the items will be placed in the trunk. Everyone must have a MASK on at all times.

All volunteers will have on MASKS, FACE SHIELDS and GLOVES.

Saturday is the only day scheduled event. If you have question or concerns please call 954-524-4920 or email info@sicklefreebroward.org.