Bleeder & a Buddy

North Star Reach in Pinckney, MI

Join us for our annual Bleeder & a Buddy teen retreat! Affected teens between the ages of 13 and 17 are invited to bring a non-affected "buddy" to this weekend retreat.

The weekend will include icebreakers, games, and opportunities to share information about bleeding disorders with non-affected friends. Each person who brings a friend to the retreat leaves with a friend who has a much better understanding of their bleeding disorder.

Friday, October 17th
4:00 pm arrive at HFM (1921 W. Michigan Ave., Ypsilanti, MI 48197)
4:30 pm depart for North Star Reach
5:30 pm arrive at North Star Reach (1200 University Camp Drive
Pinckney, MI 48169)

Sunday, October 19th
9:30 am leave North Star Reach
10:30 am arrive at HFM

For more information please contact Travis Miller or Gelli Kelley

734-544-0015

"I understand that, in order to attend Bleeder & a Buddy, I will need to provide proof of full COVID-19 vaccination."*

Yes

I am a:*

BleederBuddy

With whom will you be attending?*

How old are you?*

Over 18Under 18

Participant's Name*

First NameLast Name

Preferred Name

Birth Date

MM/DD/YYYY

Phone Number*

E-mail*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Photo of COVID-19 Vaccination*

Browse Files

Parent/Guardian Name*

First NameLast Name

Primary Phone*

Secondary Phone

E-mail

Emergency Contact*

First NameLast Name

Relationship to Teen*

Primary Phone*

Secondary Phone

Bleeding Disorder Information: Please check all that apply*

	Select	Severity	vWD Type	Inhibitor?
Hemophilia A (factor 8 deficiency)
Hemophilia B (factor 9 deficiency)
von Willebrand Disease
Platelet Disorder
Hemophilia A Carrier
Hemophilia B Carrier
Other

Do you have any other bleeding disorders*

YesNo

Other bleeding disorder*

Please include type and severity

Are you on home infusion therapy?*

YesNoNot Applicable

Do you self-infuse?*

YesNoNot Applicable

Are you on prophylaxis treatment?*

YesNo

***If on prophylaxis, please treat before arriving on Friday so you are covered for the weekend***

Do you have a target joint/area of frequent bleeding?*

YesNo

If yes, what joint/area?*

Treatment Product Information: Please check all that apply*

	Select	Name of Product	Dosage for Minor Bleeds	Dosage for Major Bleeds	Treatment Schedule
Factor 8
Factor 9
NovoSeven
FEIBA
Stimate/DDAVP
Hemlibra
von Willebrand Factor
Other

Have you ever had a reaction to any product used for treatment of bleeding?*

YesNo

If yes, please explain.*

Primary Doctor

Primary Doctor Phone

Hemophilia Treatment Center

HTC

HTC Phone

Other pertinent health history: (ADHD, allergies, asthma, etc.)

Please explain any dietary restrictions

Medications:

	Name	Dosage	Frequency
Medication
Medication
Medication
Medication
Medication

***All medications must be in original labeled containers***

"I understand that all medications must be in original labeled containers."*

I understand

***Participants must bring their own medications, factor, factor log sheets and supplies***

Insurance Company Name

Policy or Member Name

Policy Number

Phone Number

Pick One*

I will meet the group at HFM in Ypsilanti at 3:30 pm on Friday for transportation to North Star Reach.I will provide my own transportation to and from North Star Reach.I need help arranging transportation.

I understand that I and/or my minor child will be transported by HFM designated staff and/or volunteers OR a chartered bus service to and/from North Star Reach for the Bleeder and a Buddy event.

I hereby give permission and release/discharge the Hemophilia Foundation of Michigan, its officers, agents, and employees from any and all claims or liability for personal injury or property damage that may arise from me and/or my child being transported to and/or from North Star Reach.

In the event that I and/or my child are injured while being transported and require the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed medical practitioner for me and/or my minor child. In the event treatment is called for, which a physician and/or hospital personnel refuse to administer without my consent, I hereby authorize the lead adult of the group to give such consent for me/parent/guardian if I/emergency contact cannot be reached by telephone at one of the numbers on file, or if, because of an emergency, there is not time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for me/parent/guardian, I/parent/guardian agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of consent. I/parent/guardian also acknowledge that I/parent/guardian will be ultimately responsible for the cost of any medical care, should the cost of that care not be covered or reimbursed by the health insurance carrier.

By signing my name below, I certify that I have read the above information. My signature also certifies my understanding of and agreement with the above policy.

Signature*

Parent Signature*

By signing below, I give the Hemophilia Foundation of Michigan and/or its assignees all rights, title, and interest in whatever photographs and/or video footage in which I/my minor child may appear, for the purposes outlined below, without compensation to me.

I further authorize the use of my/my minor child’s statements and testimonials, narration of services provided to me, narration of service outcomes, articles, stories, or other such literary, artistic, or educational value, and consent to the copyright and fair use of same, in accordance with all applicable trademark and copyright laws.

I further release HFM, its Board, its officers and representatives from any and all claims of any nature arising from any medium and/or publication.

Section B:

This authorization and assignment is intended for, but not limited to, the publication of promotional documents, pamphlets, brochures, news articles, charitable drives, website use, agency advertising, and other such marketing materials.

I therefore give the Hemophilia Foundation of Michigan the absolute right and permission with respect to items listed in Section A to use, re-use, publish and re-publish the same in whole or in part, separately or in conjunction with other information, photographs, video, etc. in any medium now or hereafter known, and for any purpose whatsoever, including but not limited to illustration, promotion or advertising.

Section C:

I hereby affirm that I am of full age and have the right to contract in my own name or on behalf of my minor child. I have read the foregoing and fully understand the contents hereof. This release shall not expire and will be binding upon me and my heirs, legal representatives, and assignees.

By signing my name below, I certify that I have read the above information. My signature also certifies my understanding of and agreement with the above policy.

Signature*

Parent Signature*

This form must be signed in order for teen to attend.

This health history is correct and complete as far as I know. I hereby give permission to the camp to provide, seek, and consent to routine health care, administration of medications and emergency treatment for my child, as may be necessary, including, but not limited to x-rays, routine tests and treatment and/or hospitalization. I also give permission for the camp to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. In the event that I cannot be reached in an emergency, I give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for my child.

It is my intention that the camp be treated as acting in loco parentis for my minor child. Further, it is my intention that the appropriate representative of the camp be treated as "personal representatives" for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR 164.510 (b)) to the disclosure to camp representatives of the protected health information of the person herein described, as necessary : (i) to provide relevant information to the camp representatives
related to the person's ability to participate in camp activities; and (ii) in the case of minors, to provide relevant information to the camp representatives to keep me informed of my child's health status.

I understand that my child’s protected health information will be used and disclosed to camp personnel on a need-to-know basis. The camp health center personnel will have complete access to my child’s medical record and may disclose this information to other health care providers to provide, coordinate or manage my child’s health care treatment while at camp.
I understand that other camp personnel will receive only the minimum information necessary to carry out their job duties.

By signing my name below, I certify that I have read the above information. My signature also certifies my understanding of and agreement with the above policy.

Signature*

Parent Signature*

By checking this box, you agree to abide by and engage in conduct that is beneficial to health and safety while attending the event if requested. This may include, but is not limited to temperature checks, wearing a mask, taking a Covid test, engaging in appropriate physical distancing, and not attending the event if you are ill or have exhibited symptoms of an illness.

By checking this box, you acknowledge and understand the following: 1. Participation includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; 2. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of HFM, event sponsors and venues; and 3. I hereby knowingly assume the risk of injury, harm and loss associated with the Activity, including any injury, harm and loss caused by the negligence, fault, or conduct of any kind on the part of HFM, event sponsors, and venues.

By checking this box, you understand and agree to stay home and not attend this event, if you have tested positive for COVID-19, are waiting for COVID-19 test results, have COVID-19 symptoms, feel sick or unwell, or if you have had close contact with a person who has tested positive for or who has sumptoms of COVID-19.

By checking this box, you understand that campers will be tested for COVID-19 on-site and that you have the option to test at home first and email HFM staff the negative results of the COVID-19 test.

Print Name*

Print Name of Parent/Guardian*

Signature*

Parent Signature*

Bleeder & a Buddy

STRICT REGISTRATION DEADLINE: October 10th, 2025

Emergency Contact Information

Medical Information

Insurance Information

Transportation Information

Transportation Waiver

Photo Release

Authorization for Participation

Personal Accountability Committment