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Teen Retreat

Gateway Hemophilia Association's Teen Retreat will be held Friday, April 20 through Saturday, April 21 at Camp Wartburg in Waterloo, IL. Children must live within GHA's service area and have a bleeding disorder. Siblings are also invited to attend. All attendees must be between the ages of 13-18. The purpose of the Teen Retreat is to enjoy a fun weekend of camp activities, team-building and leadership development. GutMonkey will be our guest facilitator. The Gateway Hemophilia Association and the staff of volunteers want this to be an exceptional experience for all teens!

Participant's Name (teen with a bleeding disorder)*
First Last
Date of Birth*
MM slash DD slash YYYY
Age on 4/20/2018*
Gender*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bleeding Disorder Diagnosis:*
Severity (if applicable)*
Name of Factor/Medication
Dose & Frequency
Is the participant on prophylaxis*
Who does the infusion?*
How is the infusion delivered:*
Do you have an inhibitor?*
Are there any target joints?*
If yes, please list target joints
Primary doctor*
Primary doctor's phone #*
Name of your bleeding disorder doctor (hematologist):*
Phone number of your bleeding disorder doctor (hematologist):*
ALLERGIES
My teen is allergic to:
Allergies and reaction (if applicable)
IMMUNIZATION HISTORY: Has your child been immunized for any of the following? (Click on each item that your child has been immunized for)*
- MMR (Measles, Mumps, Rubella)
- Chicken Pox
- Whooping Cough (Pertussis)/DTap/TdaP
- My child has never been immunized
- Date last Tetanus booster/DTaP/TdaP
Date
MM slash DD slash YYYY
Name of Parents or Guardian:*
Parent/Guardian's Phone #*
Parent's Email*
Parent's Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company*
Policy Number*
Name of person who carries the plan*
Arrival at Teen Retreat (5:00-6:00 p.m.) on 4/20/18*
Pick up from Teen Retreat on 4/21/17 at 3:00 p.m.*
Any dietary concerns for participant?
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.
Exclusions
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Is your teen bringing a sibling age 13-18 to the retreat?*
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
Sibling's Name
First Last
Sibling's Date of Birth
MM slash DD slash YYYY
Sibling's Gender
Sibling's Medical Challenges
The sibling is allergic to:
Allergies and reaction (if applicable)
Any dietary concerns for sibling participant?
IMMUNIZATION HISTORY: Has the sibling been immunized for any of the following? (if sibling is attending too, click on each item the sibling has been immunized for)
- MMR (Measles, Mumps, Rubella)
- Chicken Pox
- Whooping Cough (Pertussis)/DTap/TdaP
- My child has never been immunized
- Date last Tetanus booster/DTaP/TdaP
Date
MM slash DD slash YYYY

Teen Retreat

Teen Retreat

ALLERGIES

AGREEMENT, CONSENT, WAIVER AND RELEASE FORM

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.

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