CSH Membership Application

By filling out this form, I am applying for membership in the Czech Hemophilia Society.

Personal Information

First Name

Last Name

Date of Birth *

I am

Person with hemophiliaPerson with von Willebrand diseaseLegal guardianOther

Disease type and form (Hemophilia A/B, inhibitor, etc.)

Address

Street and Number

City

Postal Code

Contact

Phone

Note

For Legal Guardians

Child's full name (if applying as a legal guardian)

Child's Date of Birth

Personal Data Processing Consent

In accordance with Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data (General Data Protection Regulation), I consent to the processing of my personal data by the Czech Hemophilia Society (Český svaz hemofiliků, z.s.), ID: 00676161, with registered office at U nemocnice 1, 128 20 Prague 2. The provided data may be processed and stored for the purposes of the society's activities in assisting people with hemophilia and other bleeding disorders, specifically: name, surname, address, email address, phone number, and information about the type and form of the bleeding disorder. I hereby give my explicit consent to the above processing. I give this consent for the duration of my membership and I am aware that the consent is voluntary and may be withdrawn at any time.

I consent to the processing of personal data *