2022 HDSA National Youth Alliance Youth Retreat Registration

What happens at an HDSA National Youth Alliance (NYA) Youth Retreat?

  • Incredible opportunities to learn, bond and meet other young people who are affected by Huntington’s disease.
  • Educational sessions led by professionals on topics that are important to youth affected by HD & JHD.
  • Fun activities and games!

Who can attend?

  • Young people aged 12-29 whose lives are touched by Huntington’s disease.

Do youth under 18 have to be accompanied by an adult?

  • Yes! If you are under 18, you need to be accompanied by a parent, legal guardian or older sibling who is over the age of 22.

How much does the Youth Retreat cost?

  • Nothing! It’s free! There is no registration cost or attendance fee thanks to a generous educational grant from Teva Pharmaceuticals.
  • The NYA is also providing transportation reimbursement up to $350 for attendees! Reimbursement rates vary depending on accessibility. Reimbursements can be provided for airfare, gas or train fare. Airfare and train fare reimbursed for coach class tickets only.

What if I live far away?

  • Not a problem! HDSA has hotel rooms reserved for youth and their parents who have to travel to attend the Retreat.
  • The cost of hotel rooms (including taxes) are paid for by HDSA

Do I need to submit Medical information?

  • Yes! If you are currently receiving any medical treatment, or are taking medications you or your parent will need to fill out the medication information sheet
  • Attendees and/or Parents or Guardians are responsible for the medical care of themselves or their children while attending the event.

PART 1: General Information- To be completed by Parent or Guardian for youth under 18, and individual if over 18

Which Youth Retreat would you like to attend? (please check one) *
Have you attended any previous Youth Events? *
If yes, which one?
How do you plan on traveling to the Youth Retreat? *
Check which night(s) you will need a hotel room (remember, the retreat spans 2 days and begins at 9:00 am.) *
Do you/your child have a diagnosed medical illness or condition that we should be aware of? *
 
Please check any special needs you or your child may have

Parent/Guardian or Emergency Contact Information

Will the person above be accompanying the youth to the retreat? *
 

Part 3: Consent Forms

Media Release & Special Permissions

I give my permission and approve the use of my child or my own image, name or biographical information and/or audio recording to be used by the Huntington’s Disease Society of America as part of its promotion, advertising, publicity or fundraising efforts to support future Youth Retreats. I understand and agree that my image, information and/or audio recording may appear in any media now known or hereafter invented including but not limited to print materials, video and online presentations. I hereby waive any right to inspect and approve the uses to which it may be applied. Nothing herein will constitute any obligation on the Huntington’s Disease Society of America to use any of the above rights. *
I give my family and/or my child to participate in confidential and voluntary feedback survey of the NYA Youth Retreat. *
I am aware that in the course of the retreat staff and facilitators will be discussing Huntington’s disease, and youth issues related to Huntington’s disease, including but not limited to mental health, disease progression, dating and relationships, and sharing family stories related to Huntington’s disease. Personal information shared at the retreat will be kept confidential, with exceptions of reports of abuse, neglect, or intent to harm self or others as required by law *
Waiver of Liability and Indemnity: In light of ongoing concerns regarding COVID and other communicable health risks, HDSA will implement health and safety protocols appropriate to the public health circumstances existing at the time of the NYA Youth Retreat. HDSA will exercise reasonable efforts to utilize protocols that will comply with or exceed any federal, state and local public health requirements and be consistent with then-prevailing public health standards. Those protocols may include the following: vaccination, proof of COVID status, self-monitoring, symptom checkers, contact tracing, use of personal protective equipment and social distancing, or other similar measures. *
By registering for the NYA Youth Retreat, I hereby assume all risks associated with, resulting from, or arising in connection with, participation, in any capacity, in any Convention-related activities, including, without limitation, all risks of theft, loss, harm, damage, illness or sickness (including those caused by known or unknown infectious or communicable disease such as COVID, H1N1, or other illness or sickness caused by bacteria, fungi, microorganisms or viruses), or injury to the person (including death) or property damage, whether caused by negligence, intentional act, accident, act of God, or otherwise. *
Signature of attendee/parent guardian *
clear
Medications: *
Do you/your child have an epi pen *
 

Permission for use of Common Medications:

The following is a list of common, minor ailments and the medications used to treat them.

Ailment/Symptom                  Medication

Headache/Fever                   Tylenol/Advil (or generic equivalent)

Upset Stomach                     Tums, Pepto (or generic equivalent)

Minor allergies                       antihistamine, Benadryl, Claritin

Diarrhea                               Kaopectate (or generic equivalent)

                Dosage for all will be as directed on the package

In the event that I (or my child) were to suffer from any of the common ailments listed above, I give permission for a Retreat staff/volunteer to follow the protocol listed above to treat my or my child’s condition. *
Signature of attendee/parent guardian *
clear

Part 4: Medication Information Form

Medications
 MEDICATION NAME brand, generic name, doseMEDICATION DOSE & TIME OF ADMINISTRATIONHow many pills taken at a time?
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5