Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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Do you treat Prophylactically? *

YES

NO

Parent's Name *

First Name

Last Name

Parent's Number *

(###)

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Emergency Contact *

Please list an addition person's name in case of an emergency.

First Name

Last Name

Emergency Contact's Number *

(###)

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Doctor's Name *

First Name

Last Name

Doctor's Number *

(###)

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Release and Indemnification *

RELEASE AND INDEMNIFICATION: By registering your child(ren) or yourself for the Oklahoma Hemophilia Foundation Teen Retreat, you hereby assume all of the risks for your child(ren) or yourself of participating in such events and/or activities. Further, you hereby release, indemnify, defend, discharge and hold the Oklahoma Hemophilia Foundation and its Board of Directors, employees, agents and representatives harmless from and against all liabilities, claims, damages, injuries, losses, causes of actions and costs and expenses (including, without limitation, reasonable attorneys’ fees) directly or indirectly arising out of or attributable to your child’s (children’s) or your participation in the above-described events and/or activities. By registering for your child(ren), you hereby acknowledge that you are the parent or legal guardian of the minor child(ren) named in this registration and have the legal authority to execute this release and indemnification on behalf of the child(ren) named in this registration.

I Agree. Please Register.

For your information, there will not be medical personnel on site to do infusions. If you have a bleeding disorder, please plan to pretreat if that is in your treatment plan and bring extra factor in case there is an emergency. We will contact parents and the HTC in the case of an emergency. *

I have read and understand this statement.

Clothing guidelines: This is an athletic activity and all participants should choose modest clothing appropriate for outdoor play. Both boys and girls and adults must have clothing that covers their midriff except boys when on/in the water. Water shorts are recommended for girls due to the athletic nature of the event. Running shoes, shoes for in the water, and a hat should be worn. *

I understand the clothing guidelines and understand that I may be asked to change if my clothing isn't appropriate.