Screen Reader Mode Icon

Question Title

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

Question Title

* 2. Name and relationship to person with bleeding disorder.

Question Title

* 3. Full name and age (must be 18+) of spouse or Partner that you will be registering. Please choose only one.

Question Title

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

Question Title

* 5. Please provide email address.

Question Title

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

Question Title

* 7. Will you be staying both Friday and Saturday night in hotel accommodations?

Question Title

* 8. Do you or your spouse/partner have any food allergies? If so please provide name and allergen.

Question Title

* 9. LHF will provide mileage reimbursement if you live 50+ miles away from the event location. Please provide your address if you would like to receive reimbursement .

Question Title

* 10. 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 2022 Couple's Retreat, 9/23-25/2022, 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 2022 Couple's Retreat, 9/23-25/2022, 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 2022 Couple's Retreat, 9/23-25/2022, 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 F 2022 Couple's Retreat, 9/23-25/2022, 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.

Question Title

* 11. Questions or comment? We welcome all!

0 of 11 answered
 

T