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* 1. Registrant's full name and age. 

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* 2. List below the full name(s) and age(s) of guest who will be attending with you. If none, please enter N/A.

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* 3. Email Address

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* 4. Phone Number

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* 5. Have you ever attended LHF's Louisiana Capitol Advocacy Day before?

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* 6. Will you be able to attend the educational training session Monday, May 16th at 6PM?

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* 7. Will you require hotel accommodations (Provided by LHF)?

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* 8. Will you be requiring transportation/mileage reimbursement? If so please provide your address. (Those requesting reimbursement must live at least 50 miles from the Capital.)

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* 9. 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 Capital Advocacy Days, 5/16-17/2022, 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, and any family members and minor children I am registering, may be exposed to or infected by COVID by attending the LHF Capital Advocacy Days, 5/16-17/2022 , 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 Capital Advocacy Days, 5/16-17/2022, 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, 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 Capital Advocacy Days, 5/16-17/2022, 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.

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* 10. Questions or comments? We welcome all!

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