NEHA Teen Retreat Registration Form 2026

NEHA BLeader Teen Retreat Registration

Please read all instructions carefully and complete the form below accurately.
Name of Attendee:*

First NameLast Name
Preferred Name or Nickname:
Email of Attendee*
example@example.com
Phone Number of Attendee*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Address:*

Street Address

Street Address Line 2

CityState

Zip Code
MaleFemaleNon-binaryTransgenderIntersexPrefer to describePrefer not to discloseOther
She/HerHe/HimThey/ThemPrefer not to shareOther
Alaska Native or American IndianAsianBlack or African AmericanHispanic or Latino NativeHawaiian or Other Pacific IslanderWhiteMulti EthnicOther
Birth Date:*

MonthDayYear
Date of Retreat

MonthDayYear
Date
Retreat Date-Birth Date
Age at Retreat
EnglishSpanishOther
Teen with bleeding disorderSibling of someone with bleeding disorderSpeaker or Health Care ProviderIndustry PartnerOther
This will be my first time attending1 year2 years3 or more years
Adult Extra SmallAdult SmallAdult MediumAdult LargeAdult XLAdult XXLAdult XXXL
YesNo
Please describe your accommodation request.
If known, please share the name of any teens you would be comfortable rooming with at the retreat. *NEHA does NOT guarantee that they can accommodate all rooming requests.*
Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Relationship to Registrant:*
Second Emergency Contact Information
2nd Emergency Contact Name:*

First NameLast Name
2nd Emergency Contact Phone Number:*
Format: (000) 000-0000.
2nd Emergency Contact Email
example@example.com
2nd Emergency Contact Relationship to Registrant:*
Diet and Activity
YesNo
Diet Restrictions-Please Explain*
YesNo
Activity Restrictions-Please Explain*
Allergies and Medications
YesNo
FoodMedicationEnvironmental
Please list any allergies indicated above:*
YesNo
Please indicate which allergies listed above have risk of anaphylaxis.*
YesNo
Bleeding Disorder Questionnaire

Please answer questions about this child/registrant only
YesNo
Factor I (1) deficiencyFactor II (2) deficiencyFactor V (5) deficiencyFactor VII (7) deficiencyFactor VIII (8) deficiencyFactor IX (9) deficiencyFactor X (10) deficiencyFactor XI (11) deficiencyFactor XII (12) deficiencyFactor XIII (13) deficiencyVWD Type 1VWD Type 2VWD Type 3Platelet DisorderOther
Please explain further the severity, type, and any other notes on your bleeding disorder diagnosis here*
Boston Hemophilia Center (Brigham and Women's)Boston Children'sConnecticut Children's Hemophilia CenterDartmouth-HitchcockMaine Hemophilia Treatment Center (Scarborough)Maine Hemophilia Treatment Center (Bangor)Massachusetts General HospitalNew England Hemophilia Center (UMASS Memorial Hospital)Rhode Island Hemophilia Center/BrownUCONN Hemophilia CenterVermont Regional Hemophilia CenterYale New Haven Hemophilia CenterOther
Primary Hematologist Name*

First NameLast Name
Primary Hematologist Phone Number*
Format: (000) 000-0000.
Primary Hematologist Address*

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
ProphylaxisOn-DemandOther
YesNo
Please list the medication, dosage, AND frequency for all medications taken for your bleeding disorder/disorders.*
YesNo
Please explain any adverse reactions to bleeding disorder medications*
YesNo
Please explain which device/devices you use for administration of medications*
butterfly needle, port, PICC line, etc.
YesNoOther
YesNoOther
YesNo
YesNo
Please note any problem body parts or "target joints" here
Other Medical Conditions

This section is to reference medical conditions NOT pertaining to a bleeding disorder
YesNo
Please explain these medical conditions.*
YesNo
Please list any medications you will be bringing, dosage, and frequency of use.*
YesNo
Please explain what support you will need to manage this medical condition at the retreat.*
YesNo
Please explain/list history here.*
YesNo
Details:*
YesNo
Details:*
Share anything you would like NEHA's Retreat Staff to know about you. Please include strengths, interests, and/or anything else you believe could help smooth your process of attending the retreat.
Our BLeaders retreat aims to build independent living skills, including managing a bleeding disorder, leadership development, and connections between teens. Are there specific topics that you are interested in learning about based on the program’s objectives? For example: talking to your HTC team, public speaking and professional communication, mental health, support for siblings, etc. Your feedback will help us build the agenda for the weekend.
Immunizations
YesNo
Please upload documentation of your immunizations: Alternatively, you may email immunization records to info@newenglandhemophilia.org or fax them to 781-329-5122.

Cancelof
Insurance
YesNo
Health Insurance Carrier*
Policy Number*
Group Number (if applicable)
Authorizations
Participation Policy

By registering for this event, you agree to our Participation Policy:

You are expected to participate in the entire program (see dates and times listed on the event webpage) and attend all meals, sessions, and activities. When attendees do not participate in the full length of the program, it affects our planning and we lose valuable funds for food and activities that have been paid for in advance. If your schedule does not align with the program schedule, it is your responsibility to contact us.
AgreeDisagree
Liability Waiver

By registering for this event, you agree to our Liability Waiver:

I, the undersigned, hereby hold harmless, waive and release New England Hemophilia Association, their childcare workers, officers, representatives, agents, organizers, and successors from liability as a result of (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease including, without limitation, COVID-19, while I attend this event and/or my child/children are enrolled in childcare and, if applicable, at an off-site Field Trip and/or during transportation to and/or from an event or field trip.

I have read, understand, and agree to adhere to the childcare policies and procedures of NEHA:

1) Do not bring a sick child to childcare or youth programming. Examples: fever/productive cough/excessive runny nose/nausea.

2) NEHA is not responsible for items lost in childcare or youth programming.

3) Please have your cellphone on you at all times, in case of emergency.

4) Children will only be released to the person who dropped them off, unless otherwise notified.

5) Volunteers and staff will not change diapers. Childcare will notify caregivers with a call or text so they can come and change the child in a timely manner.

6) Children are expected to be dropped off and picked up at the times listed in the event program. Please notify NEHA Staff if you have a change in plans or timing.

7) If your child has a food allergy, please provide their own labeled snack/drink. Please discuss all allergies with childcare at drop-off as well.

8) Children who are allowed to attend an off-site field trip will be under the care of chaperones. Parents are responsible for sending emergency medical supplies with chaperones.
AgreeDisagree
Media Policy

By registering for this event, you agree to our Media Policy:

I hereby grant the New England Hemophilia Association permission to reproduce, publish, circulate, copyright or otherwise use any and all photographs and/or videotape of me and/or my family taken during this event.
AgreeDisagree
Cancellation Policy

By registering for this event, you agree to our Cancellation Policy:

If you cancel your registration within one week of the event or do not show up for the event, you will be charged a $30 per person fee.

If you are sick or are experiencing a personal or medical emergency, of if you have questions about this policy, please contact us to discuss at: info@nehemophilia.org.
AgreeDisagree
Behavior Agreement

By registering for this event, you agree to our Behavior Agreement:

All attendees are expected to treat each other with kindness and respect while participating in this event. Parents are expected to watch their children when they are not under the supervision of volunteers in childcare or youth programming. Personal issues should be treated with discretion and any concerns should immediately be brought to the attention of a NEHA Staff Member or Volunteer in the room. Bullying and cyber-bullying are prohibited at NEHA events. If an issue is reported or detected, NEHA Staff will contact parents and the participants involved may be asked to leave the track for kids and/or teens.
AgreeDisagree
Release of Bleeding Disorders Medical Records

You and your parent/guardian, authorize any minor child's bleeding disorder clinic, as listed on their application , to release protected health information including any relevant records pertaining to their bleeding disorder and the management of this disorder to the medical staff at NEHA's BLeaders Teen Retreat for the purpose of attending the event. You and your parent/guardian also agree to allow communication between NEHA and your HTC for the purpose of collaboration and information sharing about your attendance at the retreat and management of your bleeding disorder while attending the retreat.
AgreeDisagreeN/A
Digital Signature

By registering for this event, you agree to following our Participation Policy, Liability Waiver, Behavior Agreement, Media Policy and Cancellation Policy. Please review all policies above.

If you are the guardian of a child attending this event, you agree to these policies on their behalf.

If you agree with these policies, please write your name here as a digital signature.
Teen Digital Signature
Typing your full name here marks your signature.
Adult/Parent/Guardian Digital Signature
Typing your full name here marks your signature.
Should be Empty:

NEHA BLeader Teen Retreat Registration

Emergency Contact Information

Second Emergency Contact Information

Diet and Activity

Allergies and Medications

Bleeding Disorder Questionnaire

Other Medical Conditions

Immunizations

Insurance

Authorizations