Young Adult Hike

GHA will host a day hike for young adults within our service area. They must be ages 19-25 with a bleeding disorder and they may bring a significant other. The group will depart for the hike from The Lodge of Four Seasons on Friday, April 16, 2021 at 9:30 a.m. This 4 mile hike will be at Lake Ozark, MO. The objective is for young adults to connect and grow in a safe environment. GHA and the staff of volunteers want this to be an exceptional experience for all! Qualified volunteers and a nurse will be on the hike to address any issues that arise during the hike. GHA feels that education is a very important aspect of every program and have included educational components with the goals of building self-confidence, management of their disorder, positive attitudes, appropriate decision making skills and independence. It is our hope that the young adults will be empowered to be leaders in the community and make lifelong friendships. Please wear proper clothes and shoes for hiking. Check the weather prior to the hike to prepare. Lunch, and snacks provided. Please contact Bridget at info@gatewayhemophilia.org or (314) 482-5973 with any questions. Registration closes 3/26.

Participant's Name*
First Last
Significant Other's Name (if applicable)
First Last
Date of Birth*
MM slash DD slash YYYY
Significant Other's Date of Birth (if applicable)
MM slash DD slash YYYY
Participant's Gender*
Significant other's Gender
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
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
Name of your bleeding disorder doctor (hematologist):*
Phone number of your bleeding disorder doctor (hematologist):*
ALLERGIES
I am allergic to:*
Allergies and reaction (if applicable)
What kind of insurance do you have? (Your answer is optional. Knowing this information allows us to be informed and better advocates for our community.)*
Today's Date
MM slash DD slash YYYY
Name of emergency contact:*
Emergency Contact's Phone #*
Any dietary concerns for participant or significant other?
AGREEMENT, CONSENT, WAIVER AND RELEASE FORM
Please read this information completely before signing. Its effect is to release the Gateway Hemophilia Association (GHA) from any liability resulting from your participation in the program activity named above and waives all claims for damages or losses against GHA. 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 their member officers, volunteers, 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 it will be necessary for me to bring my medication for my bleeding disorder. If a diagnostic procedure, hospitalization, or other specialized therapy is needed, the cost of such care is my responsibility. 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 significant other's participation in normal or unusual acts associated with the above named program. I believe that I am in good health, and affirm that my 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, video or motion pictures may be taken of the named applicant during the hike, and that said photographs, video or motion pictures may be published in newspapers, magazines, television, 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 staff or director of GHA. 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. With the understanding that the GHA will make every reasonable effort to prevent accidents, injuries, or other mishaps, I acknowledge the following: The undersigned does hereby agree to allow participation of applicant in all activities (except those restricted) The undersigned gives permission for the applicant to ride in vehicles operated or leased by the GHA. The undersigned recognizes the right of the Executive Director, in his/her absolute discretion, to terminate a participant's hike at any time due to disciplinary or medical actions which might jeopardize the participant's or others health and safety on the hike. The undersigned agrees not to participate if he or she has been exposed to a contagious disease within three (3) weeks of April 16, 2021, and to notify GHA if this situation arises.

CONSENT TO RELEASE HEALTH INFORMATION UNDER HIPAA ACT I understand and acknowledge the following: • That the young adult hike is a program sponsored by the Gateway Hemophilia Association • That hike is conducted by volunteers • Information submitted on registration forms may contain health information • The protected health information can be used and disclosed to healthcare organizations for the purpose of treatment, healthcare operations and payment for medical treatment while I attend the hike • That hike volunteers of the Gateway Hemophilia Association may have access to information contained in the healthcare record or hike registration forms, as needed, to conduct the program.
Exclusions
List any current medical conditions listed above or any others requiring medical treatment or special consideration on the hike.
Individuals with moderate to severe Hemophilia and other bleeding disorders should be treated with regular, scheduled infusions of factor (prophylaxis) while on the hike, so that they can fully enjoy all activities without fear of bleeding episodes. Those with moderate to severe hemophilia should administer their prophylactic dose the morning of the hike before arriving at the drop off point.

Young Adult Hike

ALLERGIES

AGREEMENT, CONSENT, WAIVER AND RELEASE FORM