Screen Reader Mode Icon

Crowne Plaza Hotel
4728 Constitution Ave., Baton Rouge, LA 70808

Question Title

* 1. Full name and Bleeding Disorder (if applicable) of adults in your family that you will be registering. At least one family member must have a bleeding disorder to attend. LHF will provide one hotel room per family.

Question Title

* 2. Full name, age, and bleeding disorder, if applicable, of all children ages 3-6 that will be attending our childcare services. Child must be potty trained.

Question Title

* 3. Full name, age, bleeding disorder, if applicable, of all youth ages 7-17 that will be attending our youth activities and sessions.

Question Title

* 4. Indirect family members or friends of those affected by a bleeding disorder may attend at a cost of $225 for up to two adults for the full weekend. (invoice will be sent to registered email address)

Question Title

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

Question Title

* 6. Please provide email address.

Question Title

* 7. Please provide your home address. Mileage reimbursement will be provided to those who reside 50+ miles away from event location of 4728 Constitution Ave., Baton Rouge, LA 70808.

Question Title

* 8. Hotel accommodations will be provided by LHF for registered patient guest only and their spouse/caretaker/support person and child(ren). One room per family. Please check room type.

Question Title

* 9. Will you be staying both Friday and Saturday night in hotel accommodations?

Question Title

* 10. Do you or any of your family members have a food allergy? If so please list names and food allergens below.

Question Title

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

Illness/Injury

By checking yes to this this agreement, I acknowledge the contagious nature of any illness and voluntarily assume the risk that I may be exposed to or infected by illness by attending the LHF Annual Meeting, 11/1-3/2024, 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 an illness at the LHF Annual Meeting, 11/1-3/2024, 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 Annual Meeting, 11/1-3/2024, 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 illness or injury occurs before, during, or after participation in any LHF program.

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

Question Title

* 12. Accident/Injury Liability Waiver

I, the undersigned, being aware of my own health, limitations, and physical condition, acknowledge that I am voluntarily participating in the LHF Annual Meeting, 11/1-3/2024.

Having such knowledge, I understand that I am solely responsible for my personal safety and hereby release LHF, its representatives, agents, and event site host from liability for any accidental injury that may result from participation in this program.

I also accept this liability on behalf of my child(ren), and furthermore agree to supervise adequately to prevent injury.

Question Title

* 13. Questions or comment? We welcome all!

Question Title

* 14. If your mailing address, email address, or phone number has changed in the last six months, please update below.

T