Country Boy Fishing
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(678) 492-0613
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Men’s Retreat May 31 – June 2 (Men’s Retreat Rehoboth, Delaware)
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Men’s Retreat May 31 - June 2 (Men’s Retreat Rehoboth, Delaware)
1
Basic Registration Information:
2
Bleeding Disorder Information:
3
Men’s Retreat Logistics:
4
Community Experience:
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Age Range (As of May 6, 2022):
(Required)
21 to 30
31 to 45
46+
Emergency Contact Name:
(Required)
Emergency Contact Phone:
(Required)
Emergency Contact Relationship To You:
(Required)
Do you consent to share information with other attendees and sponsors?
(Required)
Yes
No
Do you have:
(Required)
Hemophilia A
Hemophilia B
VWD
Inhibitor
Do you have any other medical issues
Are you or a family member employed by a specialty pharmacy or pharmaceutical manufacturer?
Yes
No
If accepted, will you be able to provide confirmation of your bleeding disorder
Yes
No
Do you have any dietary restrictions or food allergies?
Yes
No
If yes, please list
Accommodation will be double occupancy. Please confirm you are comfortable sharing a room with another Men’s Retreat member
(Required)
Yes
No
Do you need an ADA-compliant room?
Yes
No
Do you need any mobility accommodations?
Yes
No
If yes, please list
Have you attended any multi-night hemophilia community programs in the past?
Yes
No
If so, which event(s)?
Are you an active member of your local bleeding disorders chapter?
(Required)
Yes
No
If so, which chapter do you participate in?
(Required)
Do you volunteer within the bleeding disorders community?
Yes
No
If yes, please explain:
what would attending this event mean to you?
Please Check Boxes
(Required)
You are able to provide travel to and from event in Rehoboth Beach, DE at your own expense.
You are over 21
You are a male with Hemophilia A, Hemophilia B, VWD or an Inhibitor
Select All
Name
(Required)
Date
(Required)
MM slash DD slash YYYY
This event does not require proof of vaccination. Still, given that it is a multi-night event, we are asking that if you are experiencing sickness (coughing, fever, chills, nasal drip) in the days before the event, please test for COVID-19 and please remain at home if you test positive. In addition, we will encourage, but not require, rapid on-site testing at the event's start to ensure the safety and well-being of all of our participants. We will also have masks on hand for anybody wishing to wear those. I appreciate your understanding. We look forward to hosting a healthy and happy Men’s Retreat.
Please confirm the following
(Required)
I understand that this event is meant for men with a bleeding disorder and that unaffected family members (spouses, significant others, children) are not invited to attend.
