2017 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.
  • Fun activities and games!

Who can attend?

  • Young people aged 12-25 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 $400 for attendees! Reimbursement rates vary depending on accessibility.

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.
Gender *

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? *
 

Parent or Guardian Information (All Registrants)

Will the Parent or Guardian above be accompanying the youth to the retreat? *

Emergency Contact Information (if someone other than a family member is attending retreat with young person)

Please check any special needs you or your child may have

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 *
Parent/Guardian Signature *
clear
Applicant Signature *
clear
Do you/your child have an epi pen *
 
Medications: *

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 camper/parent guardian *
clear

Part 3: 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