Fusion Family Night Application

Bleeding Disorders of Kentucky Fusion Family Night
The Bleeding Disorders of Kentucky Foundation is excited to announce the second Fusion Family Night taking place in Owensboro, KY. Come join us on May 16th for community building, education, and fun at the Holiday Inn Owensboro Riverfront. Participants will be provided tickets to the Owensboro Museum of Science and History to attend following the event. Hotel stay will be included for families residing 2 or more hours away based on availability. We request only family members residing in the household of the individual with a bleeding disorder attend. We are so happy you've decided to join us for this fun family event!!

Hotel and event space is limited! Please complete your application as soon as possible to reserve your family's spot.

APPLICATION DEADLINE: MAY 2, 2026

BDoKY Fusion Family Night

Event Application
DATE: May 16, 2026

LOCATION: Holiday Inn Owensboro Riverfront

701 West 1st Street

Owensboro, Kentucky 42301
Today's Date:

MonthDayYear
Date
Individual(s) with a Bleeding Disorder First & Last Name(s):*
Primary Diagnosis/Condition(s)*
Parent/Guardian Name (if applicable):
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail Address:*
Alternate or Emergency Contact (outside the home):
Name:*
Relationship to Family:*
Phone Number*

Area CodePhone Number
Do you reside 2 hours or more away from the event location?*

YesNo
If you reside 2 hours or more away from the event location, would you be interested in hotel accommodations for Friday May 15th?*

YesNoNot Applicable
If yes, please include the number of family members attending requiring hotel accommodations.
Would you be interested in receiving future event information and newsletters from the Bleeding Disorders of Kentucky Foundation?*

YesNoI've already signed up

Family Member Medical Form
Below, please provide the total number of family members attending and requested medical information.

We request ONLY family members residing in the household of the individual with a bleeding disorder attend the event.
Number of family members attending this event:*

	Name	Age	Allergies (food/medication/none)	Relationship to Patient
HTC Patient
HTC Patient
HTC Patient
Family Member
Family Member
Family Member
Family Member
Family Member
Family Member
Family Member
Family Member

Waiver and Consent Form
Authorization and Acknowledgment: By signing this waiver and consent, I, the legal parent/guardian grant permission for myself/my children to participate in any and all activities as part of the bleeding disorders family event. I recognize and acknowledge the inherent risks that may present for myself/children including but not limited to: falls, trips, uneven ground, weather, bleeding events.

I acknowledge that the possession or use of alcoholic beverages and illegal drugs are strictly forbidden at any Bleeding Disorders of Kentucky (BDoKy) event. I understand the possession of any weapon (firearm, knife, explosives, or any other item which BDoKY may determine, in its sole discretion, is a weapon) is strictly forbidden at the event facility. I authorize (BDOKY) to release my demographic information to supporting affiliates who help with the cost of our family participating in the sponsored activities. I agree to RELEASE and HOLD HARMLESS BDOKY, the facility, its founder, trustees, directors, officers, employees, agents, affiliates, volunteers and medical staff (“Staff”) from any and all injury claims of any other nature which may result from my participation and my children's participation at the event, including travel to or from the event. I agree to indemnify and hold the staff and other children at the event harmless from any and all liability caused by my children, whether or not intentional.
Medical Consent: I give my permission for BDOKY and medical staff to administer any emergency medications needed and to provide and arrange for any necessary medical treatment, including onsite and offsite emergency care. I accept responsibility for the costs of all such medical treatment.*

I AcceptI Decline
Photography Release: In consideration of our participation during the family program, and without any further consideration from BDOKY, I hereby grant permission to the BDOKY, staff and affiliates to utilize my appearance, performance or voice in any and all manner and media for the purpose of promotion, reporting or publication. BDOKY may use our families’ photograph, likeness, voice and biographical material in connection with publication, promotion, exhibition and distribution of such material. I understand that no royalty, fee or any other compensation of any kind shall become payable to me by reason of such release and use of any photograph.*

I AcceptI Decline
Please contact the UK or ULP HTC social worker before signing if you have questions.

I have read this form carefully and have had all questions answered before signing this legal document and giving the consents and waivers contained in it. I acknowledge that this is a legal document and that any questions I have of a legal nature should be directed to my attorney. I further acknowledge I will be bound by my agreement to its terms. I represent to BDOKY that all information provided in this application and the medical information is accurate and complete and that I have the legal authority to provide consent on behalf of my children and family.
Patient/Patient's Guardian must sign.
Patient/Patient's Guardian Print Name:
Child's Print Name (if applicable):
Signature*

Clear
Date:

MonthDayYear
Date
Should be Empty:

Bleeding Disorders of Kentucky Fusion Family Night

Waiver and Consent Form