Teen Retreat

ALLERGIES

AGREEMENT, CONSENT, WAIVER AND RELEASE FORM

Please read this information completely before signing. Its effect is to release Gateway Hemophilia Association (GHA) and Living Well Village from any liability resulting from your participation in the program activity named above and waives all claims for damages or losses against GHA and Living Well Village.

In consideration of GHA making arrangements for and permitting and assisting me in participating in the above named program activities, I exercise my own free choice to participate voluntarily in activities, understand and assume all associated risks, and promise to take due care during such participation. I hereby release and discharge, indemnify and hold harmless GHA and Living Well Village, and their member officers, agents, employees and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and entities, against all claims, demands, costs and expenses, and causes of action whatsoever, either in law or equity, arising out of or in any way connected with any loss and/or bodily injury and/or disability, arising from my participation in the above named program.

I understand that infusion therapy will be provided as needed at the retreat. I understand that treatment for routine illness and acute bleeding episodes (DDAVP and concentrates) will be supervised by the medical/nursing staff. I understand it will be necessary for me to send factor concentrate and/or DDAVP to camp with my child. If a diagnostic procedure, hospitalization, or other specialized therapy is needed, the cost of such care is my responsibility. I give my authorization for the medical staff to administer medical care and administer routine medications to my child.

I understand that I am solely responsible for any costs arising out of any bodily injury and/or disability or property damage sustained through my/my child’s participation in normal or unusual acts associated with the above named program.

I believe that my child is in good health, and affirm that their participation in the above named program activities will in no way aggravate any condition(s) present. If in doubt, I will seek further medical advice.

The undersigned does consent that photographs and or videos may be taken of the named applicant during the retreat, and that said photographs and/or video may be published in GHA newsletters, publicity releases and/or other media, or program presentations by the GHA.

The undersigned, in case of emergency and in the event the undersigned cannot be reached by telephone, does hereby give permission for medical treatment by a physician or hospital selected by the medical staff, Executive Director, retreat volunteers, and others. Such permission shall include any and all medical treatment which is necessary or desirable in the absolute discretion of any such physician or hospital. This medical care shall include, but is not limited to, examinations, treatments, immunizations, injections, anesthesia, surgery, and other procedures, etc.

I have had sufficient time to review and seek explanation of the provisions contained above, have carefully read them, understand them fully, and agree to be bound by them. After careful deliberation, I voluntarily give my consent and agree to this Release, Assumption of Risk and Waiver.

Parents or guardians may indicate exclusions below if they do not want their child to participate in certain events.

SIBLING INFORMATION: only complete the questions below if you child with a bleeding disorder is bringing a sibling to the retreat who is between the ages of 14-17