Skip to content
LHF 2023 Couples Educational Retreat for Adults 18+ with bleeding disorders or a Parent of a Child and their Spouse or Partner. Register By April 17, 2023. (May 5-7, 2023, Westin Galleria, Houston, TX)
*
1.
Attendee 1 full name and age/date of birth
.
(Must be 18+).
(Required.)
Full Name
Age
Date of Birth
*
2.
Please provide us with your address, email address, and phone number.
(Required.)
Physical Address
Email Address
Phone Number
*
3.
Are you affected by a bleeding disorder?
(Required.)
Yes
No
*
4.
Spouse Partner of Someone with a bleeding disorder?
(Required.)
Yes
No
*
5.
Caregiver/Parent of Someone with a bleeding disorder?
(Required.)
Yes
No
*
6.
Which bleeding disorder are you affected by? If none please respond N/A.
(Required.)
7.
Dietary Restrictions? If so, please indicate in the comment box.
*
8.
Attendee 2 full name, age, and date of birth
(must be 18+)
(Required.)
Full Name:
Age:
Date of Birth:
*
9.
Attendee 2 address (if different than attendee 1, if not answer N/A), email address, and phone number.
(Required.)
Address:
Email Address:
Phone Number:
*
10.
Is attendee 2 affected by a bleeding disorder?
(Required.)
Yes
No
*
11.
Spouse or partner of Someone of a bleeding disorder?
(Required.)
Yes
No
*
12.
Caregiver/Parent of Someone with a bleeding disorder?
(Required.)
Yes
No
*
13.
Which bleeding disorder are you affected by? If none please respond N/A.
(Required.)
*
14.
Dietary Restrictions? If so, please indicate in comment box below.
(Required.)
*
15.
Hotel accommodations will be provided by LHF for registered guests and one spouse or partner. Please check room type.
(Required.)
King
Double Queen
None
*
16.
LHF will provide mileage reimbursement if you live 50+ miles away from the event location. Will you be requesting reimbursement?
(Required.)
Yes
No
*
17.
Assumption of the Risk and Waiver of Liability Relating to
Coronavirus/COVID/Accident:
The novel coronavirus, COVID, has been declared a worldwide pandemic by the World Health Organization. COVID is extremely contagious and is believed to spread mainly from person-to-person contact.
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 Couple's Retreat, 5/5-7/2023, could increase your risk of contracting COVID.
By checking yes to this agreement, I acknowledge the contagious nature of COVID and voluntarily assume the risk that I, and my spouse/partner that I am registering, may be exposed to or infected by COVID by attending the LHF 2023 Couple's Retreat, 5/5-7/2023, 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 Couple's Retreat, 5/5-7/2023, 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, and on behalf of my spouse/partner that I am registering, voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself or my spouse/partner that I am registering, (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my spose/partner may experience or incur in connection with my attendance at the LHF 2023 Couple's Retreat, 5/5-7/2023, or participation in LHF programming (“Claims”). On behalf of myself and my spouse/partner that I am registering, do 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.
(Required.)
Yes
No
18.
Questions or comment? We welcome all!
19.
If your mailing address, email address, or phone number has changed in the last 6 months, please update in the comment box below.
Current Progress,
0 of 19 answered
