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LHF 2025 Men's Educational Retreat for men with bleeding disorders 21+ or their male caregiver, father, or son. July 18-20, 2025, Grand Isle, LA.
Blue Dolphin Inn
2504 LA-1, Grand Isle, LA 70358
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1.
Full name and age/date of birth of male participant. (Patient, caregiver, father, son, or sibling ages 21+)
(Required.)
Name
Age/Date of Birth
Relationship to person with bleeding disorder. (If you have a bleeding disorder please reply self.)
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2.
Phone number that you can be reached at during the day.
(Required.)
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3.
Please provide email address.
(Required.)
*
4.
LHF will reimburse mileage for those who live 50+ miles away from event facility. Will you need reimbursement?
(Required.)
Yes
No
5.
Please provide your address if applying for mileage reimbursement. (Must live at least 50 miles from venue)
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6.
Would you be willing to share a cabin with someone? (Each cabin has two separate bedrooms)? If so please provide name of roommate.
(Required.)
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7.
A Louisiana
Basic
and
Saltwater
fishing license will be required for all of those who plan to participate in the fishing portion of the retreat. Fishing license can be purchased through the following website: https://www.wlf.louisiana.gov/page/recreational-fishing-licenses-and-permits
(Copy and paste into your web browser)
Are you able to purchase a license?
(Required.)
Yes
No
*
8.
Do you have any food allergies? If so, please list below. If not please put N/A.
(Required.)
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9.
Assumption of the Risk and Waiver of Liability Relating to
Illness/Injury/Accident:
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, Illness, 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 2025 Men's Retreat, 7/18-20/2025, 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 illness or injury occurs before, during, or after participation in any LHF program.
(Required.)
Yes
No
10.
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
No
11.
Questions or comments? We welcome all!
Current Progress,
0 of 11 answered