Teen Retreat Registration

You're Invited!

Join HFM for our annual spring teen retreat!

Camp Henry
5575 S Gordon Ave, Newaygo, MI 49337

Open to teens in the bleeding disorders community age 13-17
There is NO CHARGE for this event.

Come together with other teens in the bleeding disorders community for a weekend of connection, games, and fun!

Friday, March 7 - Sunday, March 9

Questions?

Contact Travis Miller (tmiller@hfmich.org) or Angellica "Gelli" Kelley (akelley@hfmich.org)

Is the participant 18 or older?*

YesNo

Participant's Name*

First NameLast Name

Birth Date*

MM/DD/YYYY

Gender

Phone Number*

E-mail*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

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.)

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 3:00 pm on Friday for transportation to Camp Henry.I will provide my own transportation to and from Camp Henry.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 Camp Henry for the Teen Retreat 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 Camp Henry.

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*

I wish to participate in the Hemophilia Foundation of Michigan’s Teen Retreat. I understand that my execution of this Waiver and Release is a prerequisite for participation in the Program. I further understand that there are risks and dangers inherent in participating in the Program.

I understand that in order to be allowed to participate in this activity, I agree to assume all risks and to release and hold harmless the Hemophilia Foundation of Michigan and their officers, agents, employees, assigns, successors in interest, contractors, agencies, officials and volunteers, and all governmental and public entities including, but not limited to, the State, County and local municipalities where the event takes place (collectively the “Released Parties”).

I intend by this Waiver and Release to release, in advance, and to waive my rights and discharge all of the persons and entities mentioned above, from any and all claims for damages for death, personal injury or property damage which I may have or which may hereafter accrue to me as a result of my participation in this Activity, even though this liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective property or equipment owned, maintained or controlled by them or because of their possible liability without fault. I understand and agree that this Waiver and Release is binding on my heirs, assigns and legal representatives.

I understand that I am solely responsible for my health and safety, and I acknowledge that I am physically capable of participating in and completing this Activity.

I have carefully read this Waiver and Release and fully understand its contents. If I am under 18 years of age at the time of registration, my parent or legal guardian has completely reviewed this Waiver and Release, understands and consents to its terms, and authorizes my participation by his/her signature below. I am aware that this is a RELEASE OF LIABILITY and a contract between me and the persons and entities mentioned above and I sign of my own free will.

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*

Teen Retreat 2025

Emergency Contact Information

Medical Information

Insurance Information

Transportation Information

Transportation Waiver

Photo Release

Authorization for Participation