2024 Men's Educational Retreat for men with bleeding disorders 21+ or their male caregiver, father, or son. March 15-17, 2024, Cypress Bend Resort, Many, LA

Registration must be received by March 1, 2024.

Question Title

* 1. Full name and age/date of birth of male participant. (Patient, caregiver, father, son, or sibling ages 21+)

Name

Age/Date of Birth

Relationship to person with bleeding disorder. (If you have a bleeding disorder please reply self.)

Question Title

* 2. Phone number that you can be reached at during the day.

Question Title

* 3. Please provide email address.

Question Title

* 4. LHF will reimburse mileage for those who live 50+ miles away from event facility. Will you need reimbursement?

Yes

No

Question Title

* 5. Please provide your address if applying for mileage reimbursement. (Must live at least 50 miles from venue)

Question Title

* 6. Would you be willing to share a room with someone? If so please provide name of roommate.

Question Title

* 7. Do you have any food allergies? If so, please list below. If not please put N/A.

Question Title

* 8. Assumption of the Risk and Waiver of Liability Relating to

Coronavirus/COVID/Accident/Injury:

The Louisiana Hemophilia Foundation (“LHF”) has put in place preventative measures to reduce the spread of COVID along with following federal and state guidelines; however, the Louisiana Hemophilia Foundation cannot guarantee that you will not become infected with COVID. Further, attending the LHF 2024 Men's Retreat, 3/15-17/2024, could increase your risk of contracting COVID.

By checking yes to this this agreement, I acknowledge the contagious nature of COVID and voluntarily assume the risk that I may be exposed to or infected by COVID by attending the LHF 2024 Men's Retreat, 3/15-17/2024, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the LHF 2024 Men's Retreat, 3/15-17/2023, may result from the actions, omissions, or negligence of myself and others, including, but not limited to, LHF employees, volunteers, and program participants and their families.

I, voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at the LHF 2024 Men's Retreat, 3/15-17/2024, or participation in LHF programming (“Claims”). On behalf of myself, I hereby release, covenant not to sue, discharge, and hold harmless the Louisiana Hemophilia Foundation, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Louisiana Hemophilia Foundation, its employees, agents, and representatives, whether a COVID infection or injury occurs before, during, or after participation in any LHF program.

Yes

No

Question Title

* 9. THE Louisiana Hemophilia Foundation (LHF) PHOTO RELEASE Consent:

I hereby grant the LHF permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of the LHF and will not be returned.

I hereby irrevocably authorize the LHF to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge the LHF from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED

Yes

No

Question Title

* 10. Questions or Comments? We welcome all.

Question Title

* 11. Has your mailing address, email address or phone number changed in the last six month? If so, please update in the comment box below.