LHF 2022 Annual Women's Retreat March 18-20, 2022 (Open to women with a bleeding disorder, female caregivers, siblings, grandmothers, or mothers of those with a bleeding disorder 21 and above.)

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* 1. Name of Registering Attendee

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* 2. Relationship to female with bleeding disorder?

Self

Caregiver

Sibling

Mother

Grandmother

Industry Partner

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* 3. Email Address

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* 4. Phone Number

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* 5. Date Of Birth

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* 6. Bleeding Disorder Type

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* 7. Will you be staying in our hotel accommodations?

Yes (Sponsoring industry partners must contact hotel with group reservation code provided in email sent for reservation.)

No

Yes, I am willing to room with a friend, caregiver, sibling, grandmother, or mother.

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* 8. Please provide name of person you are willing to room with.

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* 9. Will you be requesting mileage reimbursement for this even? If so please provide address.

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* 10. Do you have any food allergies or restrictions? If so please list.

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* 11. Please provide your t-shirt size.

Small

Medium

Large

X-Large

2XL

3XL

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

Coronavirus/COVID:

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 Women’s Retreat, 3/18-20/2022, 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 Women's Retreat, 3/18-20/2022, 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 Women's Retreat, 3/18-20/2022, 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 Women's Retreat, 3/18-20/2022, 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