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D E L E G A T E R E G I S T R A T I O N F O R M

Registration Fees (US$) EARLYBefore 21 October 2005

REGULARBefore 21 March 2006

LATEAfter 21 March 2006

MEMBER NON-MEMBER MEMBER NON-MEMBER MEMBER NON-MEMBER

Delegate 500.00 550.00 600.00 650.00 700.00 750.00

Allied Health Professional &Student 200.00 250.00 275.00 325.00 350.00 400.00

Person with Hemophil ia 100.00 150.00 150.00 200.00 200.00 250.00

Accompanying Person 100.00 100.00 100.00 100.00 100.00 100.00

The registration fee for delegates includes admission to the Opening Ceremony and reception, the Cultural/Social event onTuesday evening, as well as access to all sessions, coffee breaks and congress materials

Payment MethodsRegistration fees can be paid by credit card, bank transfer* or wire transfer*. Please include all the information listed below tomake your bank or wire transfer.

Account Name: World Federation of HemophiliaBank: Caisse Centrale Desjardins, Montreal, CanadaBranch Name: Caisse Populaire Desjardins (C.P.D.) du Sault-au-RcolletTransit: 815-30403Account Number: 800-390-7Swift Code: CCDQCAMM

*Bank charges are responsibility of the sender. Clearly indicate your family name and the note registration fee on the

transfer. The WFH 2006 Secretariat shall not be responsible for tracking transfers deposited without appropriate identification.

Cancellation and Refund PolicyParticipants unable to attend will received a refund equivalent to seventy-five percent (75%) of their paid registration feeprovided that the Congress Secretariat is advised of the cancellation in writing on or beforeApril 9, 2006. The CongressSecretariat regrets that requests received after this date will not be considered.All approved refunds will be issuedwithin one month after the congress.

Organized by: Hosted by:

Hemophilia 2006 Secretariat and Housing Bureau1425 Rn-Levesque Blvd. West, Suite 1010

Montreal, QuebecCanada H3G 1T7

Tel: +1 (514) 394-2837 Fax: +1 (514) 875-8916 Email: hemophilia2006@wfh.org

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HEMOPHILIA 2006 REGISTRATION FORMFax To: +1 (514) 875-8916

Dr. Mr. Mrs. Ms.

Last Name: ________________________________________________ First Name: _______________________________

Title: ______________________________________________________________________________________________________

Institution: __________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Address contd: __________________________________________ City: _________________________________________

Province / State: __________________________________________ Country: ______________________________________

Postal / Zip Code: ________________________________________ Tel: __________________________________________

Fax: _______________________________________________ Email: ________________________________________

Profile (select all that apply): I work mostly with: Hematologist Orthopedist Dentist Pediatrician General Practitioner

Researcher / Scientist Laboratory personnel Nurse

Physiotherapist Social Worker / Psychologist Student NMO Staff NMO Volunteer

Person with Hemophilia Family member of a person withHemophilia Other

Treatment Center or Hospital Industry Government or Regulatory Agency Non-profit Organization Other (please specify)

___________________________ I will be applying for CME credits

1. DELEGATE REGISTRATION FEE(please select one) Delegate Allied Health Professional Student Person with Hemophilia Registration Fee $

2. MEMBERSHIP to the WORLD FEDERATION OF HEMOPHILIA I would like to include a US$50 payment for my one-year membership to the WFH and immediately

benefit from the reduced member registration fee and other membership benefitsMembership Fee $

3. ACCOMPANYING PERSONSFirst Name: _______________________________ Last Name: ______________________________

First Name: _______________________________ Last Name: ______________________________Accompanying Person(s) Fee

$

4. CULTURAL SOCIAL PROGRAM Opening Ceremony and Reception on Sunday May 21 (complimentary for registered delegates andaccompanying persons) Cultural Social Event on Tuesday May 23 (complimentary for registered delegates and accompanying persons) Farewell Dinner on Thursday May 25 US$40 x _________ person(s)

COMPLIMENTARY

COMPLIMENTARY$

5. PRE-CONGRESS WORKSHOPSI am interested in attending the following workshops on Sunday May 21 (complimentary) Nurses Full Day Workshop Beginner Advanced Physiotherapy Full Day Workshop Psychosocial Full Day Workshop Laboratory Sciences Full Day Workshop COMPLIMENTARY

6. TOTAL Total Payment (Add section 1+2+3+4+5) $

7. PAYMENT Total Payment $

Bank or Wire Transfer Credit CardI authorize the WFH to charge the total amount indicated above to the following credit card: VISA EUROCARD / MASTERCARD

Card Number:

Expiry Date (mm/yy): Cardholder Name: ..

Signature of Cardholder: Date: (Authorizing charges)