2024 HDSA National Youth Alliance Retreat Application

Where is it?

Nashville, TN

When is it?

From Friday, July 26, 2024, to Sunday, July 28, 2024

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

Incredible opportunities to learn, receive support, meet and connect with other young people who are affected by HD & JoHD.
Educational sessions led by professionals on topics that are important to youth and young adults affected by HD & JoHD.
Fun activities for everyone

Who can attend?

Anyone between the ages of 12-35 whose lives are impacted by HD and JoHD.

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.
Transportation reimbursement of up to $500 for each attendee. Reimbursements can be provided for airfare, gas or train fare. Airfare and train fare are reimbursed for coach class tickets only.
Hotel accommodation for two nights will be covered.
Meals for Saturday and Sunday morning.

Do I need to submit Medical information?

Attendees and/or Parents or Guardians are responsible for the medical care of themselves or their children while attending the event.
Only medical information and accommodations that you need or would like us to be aware of will be asked.

Please note: There are limited spots available and all applicants will be notified before June 17th 2024. The application will stay open until all spots are confirmed.

If you have any questions, please contact

MaryAnn Emerick

memerick@hdsa.org

First Name *

Last Name *

Age? *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address *

Phone Number *

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

Have you attended any previous Youth Events? *

Yes

No

If yes, which one?

NYA Youth Retreat

NYA Day

HDYO North American Youth Camp

How do you plan on traveling to the NYA Retreat? *

Car

Airplane

Train

Do you/your child have a diagnosed medical illness or condition that we should be aware of? *

No

Yes (If yes, please share) Yes (If yes, please share)

Primary Language spoken by participant *

Please check any special needs you or your child may have

Mobility Issues:

Dietary Needs:

Allergies (food, medication, etc and course of treatment) :

Other:

Please share any additional information about yourself which may help us better get to know you! (How you are affected by Huntington’s disease, likes, dislikes, favorite activities or hobbies)

What would you like to get from the NYA Retreat? (topics, activities, resources etc.) *

Parent/Guardian or Emergency Contact Information

Name *

Relationship to Youth *

Phone Number *

Cell Phone Number *

Email Address *

Street Address *

Address Line 2

City *

State *

Zip Code *

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

Yes

No (if No and youth is under 18, please list information for guardian attending retreat with Youth below) No (if No and youth is under 18, please list information for guardian attending retreat with Youth below)

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. *

Yes

No

I give my family and/or my child to participate in a confidential and voluntary feedback survey of the NYA Retreat. *

Yes

No

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 *

Yes

No

Signature of attendee/parent/ guardian *

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