LHF 2024 Couples Educational Retreat for Adults 18+ with bleeding disorders or a Parent of a Child and their Spouse or Partner. Register By September 12, 2024. (October 18-20, 2024, Embassy Suites, New Orleans, LA)

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* 1. Attendee 1 full name and age/date of birth. (Must be 18+).

Full Name

Age

Date of Birth

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* 2. Please provide us with your address, email address, and phone number.

Physical Address

Email Address

Phone Number

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* 3. Are you affected by a bleeding disorder?

Yes

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* 4. Spouse Partner of Someone with a bleeding disorder?

Yes

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* 5. Caregiver/Parent of Someone with a bleeding disorder?

Yes

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* 6. Which bleeding disorder are you affected by? If none please respond N/A.

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* 7. Dietary Restrictions? If so, please indicate in the comment box.

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* 8. Attendee 2 full name, age, and date of birth (must be 18+)

Full Name:

Age:

Date of Birth:

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* 9. Attendee 2 address (if different than attendee 1, if not answer N/A), email address, and phone number.

Address:

Email Address:

Phone Number:

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* 10. Is attendee 2 affected by a bleeding disorder?

Yes

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* 11. Spouse or partner of Someone of a bleeding disorder?

Yes

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* 12. Caregiver/Parent of Someone with a bleeding disorder?

Yes

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* 13. Which bleeding disorder are you affected by? If none please respond N/A.

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* 14. Dietary Restrictions? If so, please indicate in comment box below.

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* 15. Hotel accommodations will be provided by LHF for registered guests and one spouse or partner. Please check room type.

King

Double Queen

None

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* 16. LHF will provide mileage reimbursement if you live 50+ miles away from the event location. Will you be requesting reimbursement?

Yes

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* 17. 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 Couples Retreat, 10/18-20/2024, 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 Couples Retreat, 10/18-20/2024, 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 Couples Retreat, 10/18-20/2024, 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

Yes

LHF 2024 Couples Educational Retreat for Adults 18+ with bleeding disorders or a Parent of a Child and their Spouse or Partner. Register By September 12, 2024. (October 18-20, 2024, Embassy Suites, New Orleans, LA)

Question Title

* 1. Attendee 1 full name and age/date of birth. (Must be 18+).

Question Title

* 2. Please provide us with your address, email address, and phone number.

Question Title

* 3. Are you affected by a bleeding disorder?

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* 4. Spouse Partner of Someone with a bleeding disorder?

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* 5. Caregiver/Parent of Someone with a bleeding disorder?

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* 6. Which bleeding disorder are you affected by? If none please respond N/A.

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* 7. Dietary Restrictions? If so, please indicate in the comment box.

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* 8. Attendee 2 full name, age, and date of birth (must be 18+)

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* 9. Attendee 2 address (if different than attendee 1, if not answer N/A), email address, and phone number.

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* 10. Is attendee 2 affected by a bleeding disorder?

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* 11. Spouse or partner of Someone of a bleeding disorder?

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* 12. Caregiver/Parent of Someone with a bleeding disorder?

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* 13. Which bleeding disorder are you affected by? If none please respond N/A.

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* 14. Dietary Restrictions? If so, please indicate in comment box below.

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* 15. Hotel accommodations will be provided by LHF for registered guests and one spouse or partner. Please check room type.

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* 16. LHF will provide mileage reimbursement if you live 50+ miles away from the event location. Will you be requesting reimbursement?

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* 18. Questions or comment? We welcome all!

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* 19. If your mailing address, email address, or phone number has changed in the last 6 months, please update in the comment box below.