2023 Men's Educational Retreat for men with bleeding disorders 21+ or their male caregiver, father, or son. October 20-22, 2023, Cypress Bend Resort, Many, LA

Registration must be received by September 22, 2023.

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* 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.)

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

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* 3. Please provide email address.

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

Yes

No

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

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

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

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* 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 2023 Men's Retreat, 10/20-22/2023, 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 2023 Men's Retreat, 10/20-22/2023, 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 2023 Men's Retreat, 10/20-22/2023, 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 2022 Men's Retreat, 6/25-27/2022, 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

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* 9. Questions or Comments? We welcome all.

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