Camp Old Beagle

As a social service health agency, HFM believes community and patient safety is a top priority. To ensure community members remain safe and healthy while attending HFM Eagle Journeys camping programs, HFM may require health screenings or tests prior to camp. Please self-monitor for symptoms and refrain from attending Eagle Journeys events if you are experiencing any signs of illness.

This retreat is open to all former Camp Bold Eagle and Eagle Outpost staff and campers who are at least 18 years old and their immediate family (significant other and children).

Please arrive Friday between 4pm and 7pm & depart Sunday by 4pm.

Pioneer Trails 1421 E Fruitvale Rd., Holton, MI 49425

ALCOHOL AND SUBSTANCE USE POLICY: The use or possession of alcoholic beverages or any illegal substance on the camp premises is strictly prohibited. Prescription drugs must be kept in your personal possession.

Questions? Contact Tim Wicks

twicks@hfmich.org or 734-544-0015

"I understand that there will be no medical staff or childcare provided at Camp Old Beagle and that parents are responsible for their children during the entire weekend."*

Yes

What years were you at camp?

What positions have you held at CBE or Outpost?

Number of adults attending (limit 2)*

Please only include immediate family members living at the same address.

Number of children attending. *

Please only include immediate family members living at the same address.

Adult 1 Name*

First NameLast Name

Adult 1 Email*

example@example.com

Adult 1 Phone*

If opting-in for text notifications, please provide cell phone number.

Would you like to opt-in for text notifications from HFM?

Yes

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Long-sleeve T-shirt Size*

Adult 2 Name*

First NameLast Name

Adult 2 Email*

example@example.com

Adult 2 Phone*

If opting-in for text notifications, please provide cell phone number.

Would you like to opt-in for text notifications from HFM?

Yes

Long-sleeve T-shirt Size*

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Long-sleeve T-shirt Size*

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Long-sleeve T-shirt Size*

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Long-sleeve T-shirt Size*

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Long-sleeve T-shirt Size*

Does anyone attending have any dietary restrictions?*

YesNo

Please list dietary restrictions.

Section A:

By signing below, I give the Hemophilia Foundation of Michigan (HFM) 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.

It is the policy of HFM that the confidentiality of those affected by Hemophilia and related hereditary bleeding disorders and related complications, including HIV and hepatitis, will be strictly maintained therefore any materials utilized as a result of this consent will be edited and reviewed closely to ensure that any identifying information of you and/or your child(ren) will remain confidential.

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. I understand that I may revoke this consent at any time by sending written notice of such request to the attention of HFM Executive Director: Susan Lerch 1921 West Michigan Avenue, Ypsilanti, MI 48197

Signature*

I wish to participate in the Hemophilia Foundation of Michigan’s Camp Old Beagle Alumni 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, participating committees and clubs 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.

Signature*

HFM relies on donations from community members and supporters to provide programs like Old Beagle and other services to all members of the bleeding disorders community. The pandemic added significant financial difficulties for many in our community, in addition to challenges that were already present. Please consider making a donation to assist those in need and to assist HFM in continuing to offer programs and services.

$30$20$10Other

Calculation

PAYMENT

USDTotal

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Questions? Please feel free to contact Tim Wicks at

twicks@hfmich.org, 734-961-3507.

Camp Old Beagle: Alumni Retreat

Adult 1

Adult 2

Child 1

Child 2

Child 3

Child 4

Photo and Video Release

Liability Waiver

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