Women & Girls Retreat Registration

Participant Information
Primary Contact Name*
First Last
Primary Contact Email*
We will be sending COVID updates and program registration confirmations to this email address.
Enter Email Confirm Email
Participant Cell Phone*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Bleeding Disorder | Connection to Community*
Please indicate your connection to the bleeding disorders community.
Dietary Restrictions*
Please indicate if you any dietary restrictions/food allergies. If there are none, please put NA.

Additional Attendees
Indicate below if there will be additional attendees as apart of your registration.
Additional Attendees?*
How Many Additional Attendees?*
Attendee #2
First Last
Bleeding Disorder | Connection to Community*
Please indicate your connection to the bleeding disorders community.
Attendee #3
First Last
Bleeding Disorder | Connection to Community*
Please indicate your connection to the bleeding disorders community.
Attendee #4
First Last
Bleeding Disorder | Connection to Community*
Please indicate your connection to the bleeding disorders community.
Attendee Names (under 18)*
Please list all additional attendees first and last names with age if they are under 18. Please note: childcare not provided for this event.

Emergency Contact
In the event of an emergency, please provide us with who you would like us to contact.
Emergency Contact Name*
First Last
Emergency Contact Cell Phone*
Relationship*
Please indicate your relationship to your emergency contact.

Women's Retreat Consent
Please read the following HASDC in-person event consent items below. Once your application is submitted and approved, you will receive an email from HASDC.
Photo Consent*
From time to time, the Hemophilia Association of San Diego County will want to use pictures and/or video from our events to promote bleeding disorder programs and the Hemophilia Association of San Diego County’s activities. We ask permission to be able to use your image for that purpose.

I give my permission to use my image in print, video, or electronic media, including internet and social media.
I agree to the use of photos/videos
Confirmation Email*
Once you submit your event registration, it will be reviewed. Upon approval, you will receive a confirmation email which will contain further details about the program. If you do not receive an email from HASDC within 5-days of registration, please reach out to us via email.
I have read and understand the event registration confirmation process.

HASDC's Duty of Care
HASDC’s priority is always the health and well-being of our community. Our Duty of Care is a living document that will continue to evolve, as we work closely with our sponsors, vendors, and venues to create a safety plan for our 2023 programming.
Expected Behavior for ALL Attendees:*
– Wear your name badge at all times (if provided).
– Hand sanitizing stations will be present throughout the venue for use by all attendees.
By checking this box, you agree, on behalf of yourself and additional attendees, to follow our program behavior as listed above.

Release of Liability
Please read and electronically sign the following waiver.
HASDC Events | Waiver & Release of Liability*
Assumption of Risk. HASDC has put in place recommended preventative measures with guidance from federal, state, and local officials to reduce the spread of COVID-19; however, it cannot be guaranteed that a HASDC Event participants will be prevented from an exposure to COVID-19. In consideration of being allowed to participate in HASDC Event activities, the undersigned acknowledges, appreciates, and agrees that: • The risk to have contact with individuals who have been exposed to and/or have been diagnosed with one or more communicable diseases, including but not limited to COVID-19 or other medical conditions, does exist, and it is impossible to eliminate the risk that myself and other participants could be exposed to and/or become infected through contact with or close proximity with an individual with a communicable disease; • By signing this Agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I, or other participants, may be exposed to or infected by COVID-19 by attending HASDC’s Event and that such exposure or infection may result in illness; • I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE ACTS, OMISSIONS, OR NEGLIGENCE OF OTHERS, INCLUDING BUT NOT LIMITED TO THE RELEASEES, and accept and assume sole and full responsibility for any injury to myself including, but not limited to, personal injury, disability, death, illness, damage, loss, claim, liability, action, cost, or expense, of any kind, that I may experience or incur in connection with attendance at HASDC’s Event (“Claims”); • I willingly agree to comply with the stated and customary terms and conditions for attending HASDC’s Event, including, but not limited to, CDC, State of California, and HASDC guidelines (stated below). If I observe any unusual significant hazard during my presence or participation, I will bring such to the attention of the nearest official immediately; • I, for myself, and heirs, assigns, personal representatives and next of kin, hereby release, covenant not to sue, discharge, and hold harmless the Hemophilia Association of San Diego County, the respective officers, board members, officials, agents and/or employees of each entity, other participants, sponsoring agencies, sponsors, advertisers, and the owners and lessors of the premises used to conduct the event (collectively the “RELEASEES”), with respect to any and all claims, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise; By attending an HASDC Event, I certify that I do not fall into any of the following categories: • Individuals who currently or within the past fourteen (10) days have experienced any symptoms associated with COVID-19, which include fever, cough, and shortness of breath among others; or • Individuals who believe that they may have been exposed to a confirmed or suspected case of COVID- 19. “A general release does not extend to claims which the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that, if known by him or her, would have materially affected his or her settlement with the debtor or released party.” ______By signing below, I certify that: (1) I fully and completely read and understand this COVID Waiver & Release of Liability; (2) I am 18 years of age or older; (3) the information set forth above pertaining to me is true and complete; and (4) I consent and agree to all of the foregoing on behalf of myself identified above. (5) I further acknowledge that nothing in this COVID Waiver & Release of Liability constitutes a guarantee that the Event will occur. ______This consent is on behalf of yourself and all of your additional attendees.
First Last
Today's Date*
MM slash DD slash YYYY

2023 Women & Girls Retreat

Step 1 of 6

Participant Information

Additional Attendees

Emergency Contact

Women's Retreat Consent

HASDC's Duty of Care

Release of Liability