BDoKY Fall Family Enrichment Program

Bleeding Disorders of Kentucky Fall Family Enrichment Event
The Bleeding Disorders of Kentucky Foundation is excited to announce it's fourth Fall Family Enrichment Event on Saturday, October 19th. We are so happy you've decided to join us for fall family fun at Bi-Water Farm in Georgetown, KY! In addition to educational sessions, networking activities, pumpkins, and yummy food, there will be fall family fun for everyone to enjoy. Activities include Jumping Pillows, Pirates Cove, Hayrides, Corn Maze, Spooky FarmHouse, Petting Zoo, Chutes & Slides, and a whole lot more. We are looking forward to enjoying food, fun, and education with you!

**PLEASE NOTE: There is a non-refundable $5 registration fee, PER FAMILY, that secures your spot at the event. This includes the cost of Bi-Water Farm activities, food at the event, and pumpkins for you and your family members to take home.**
Application Deadline: October 16, 2024

Space for this event is limited! Please complete your application in full as soon as possible to reserve your family's spot.

BDoKY Fall Family Enrichment

Event Application
DATE: October 19, 2024

LOCATION: Bi-Water Farm

Georgetown, KY
Today's Date:

MonthDayYear
Date
Individual(s) with a Bleeding Disorder First & Last Name(s):*
*Do you reside more than 3 hours away from Georgetown, KY?*

YesNo
Primary Diagnosis/Condition(s)*
Parent/Guardian Name (if applicable):
Street Address:
County:
City:
State:
Zip:
Phone Number*

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

Area CodePhone Number
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
Date

MonthDayYear
Date
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

To access the event tent, there will be a hayride with a step up for transportation from the parking lot and a short distance walk on uneven ground. Please indicate below if additional accommodations are needed to assist you in accessing this event.

Yes, additional accommodations are neededNo additional accommodations required

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
My Products
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Fall Family Enrichment Program Registration Fee$5.00 Fee Per Family
$5.00 Quantity

Total

$0.00
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Bleeding Disorders of Kentucky Fall Family Enrichment Event

Application Deadline: October 16, 2024

Waiver and Consent Form