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Camp Istrouma, 25975 Greenwell Springs Road

This event is offered at no charge to any Louisiana resident with a bleeding disorder and their immediate family members (caregivers/parents, spouses/partners, and siblings).  

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* 1. Full name and age of person with bleeding disorder

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* 2. Full name and age of immediate family members (caregivers/parents, spouses/partners, and siblings) that you will be registering. Registration due by April 15, 2022.

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

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* 4. Please provide email address.

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* 5. Please provide family address if you will be requesting mileage reimbursement. Must live at least 50 miles from venue to qualify for reimbursement. Reimbursement will be mailed after event.

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* 6. Do any of the guests you are registering have a food allergy? If so, please list name(s) and food allergen below. If not enter N/A.

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

Illness/Accident/Injury/Photo Release:

I, and on behalf of family members and minor children I am registering, voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself or any family members and minor children 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 may experience or incur in connection with my attendance at the LHF Friends and Family Day, 4/20/2024, or participation in LHF programming (“Claims”). On behalf of myself and family members and minor children I am registering, 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.

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

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* 8. Questions or comment? We welcome all!

0 of 8 answered
 

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