Adult Retreat Sign Up Form

Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

BD Type in Family *

Hemophilia A

Hemophilia B

vWD

Other

Room Options (depends on availability) *

(1) King bed

(2) Queen beds

No preference

Special Requests:

Vegetarian Meal

Gluten-Free Meal

Wheelchair Accessible Room

Nut Allergy

Other

Waiver *

I freely waive all rights to any future claims against the Utah Hemophilia Foundation, volunteers, or representatives due to any unforeseen circumstance that may occur during the Adult Retreat I hereby grant the release of any film, video, or other photographic images of the members of my family for use by the Utah Hemophilia Foundation for fundraising, educational or other purposes.

I Agree

*

I certify that I am free of any illness and will not attend the event if I feel any symptoms of illness, along with all members of my family. I agree to wear a mask at all times and to social distance as much as possible throughout the duration of the event.

I Agree

Registration *

*Please note, you will be directed to the UHF DONATION page. Please pay registration fee through this site.

Couple Registration: $50

Single Registration: $25

I cannot pay the full registration fee but would like to donate this amount

Request full fee waiver.