Virtual Just Us Retreat 2021

Father Information

We are excited you are interested in joining CBTF for our Virtual Just Us Retreat on October 22 (6-9PM) and 23rd (10AM-1PM Eastern). This retreat is designed to give fathers a chance to meet and bond with other fathers, provide quality time with their child, and have some fun together. The information below is used for record keeping and will help determine program content. All information is confidential. We continue to look forward to the time when we can all meet in person again. We hope to schedule an in person retreat for the spring of 2022 so stay tuned! Until then, we look forward to seeing you online!

Question Title

* 1. Father's name

Question Title

* 2. Relationship

Biological father

Step-father

Adoptive father

Other (please specify)

Question Title

* 3. Address

Address

Address 2

City/Town

State

ZIPCode

Email Address

Phone Number

Question Title

* 4. If you would you like your contact information shared with other attendees, please indicate what information we can share.

My name

My phone number

My email address

My child's name

My child's cell phone number

My child's email address

I do not want my information shared

I do not want my child's information shared

Question Title

* 5. Father's birthdate

Question Title

* 6. Father's ethnicity

African American/Black

American Indian or Alaska Native

Asian

Biracial

Hispanic/Latino(a)

Middle Eastern/Arab American

Native Hawaiian or Other Pacific Islander

South Asian/Indian American

White

Prefer not to answer

Other (please specify)

Question Title

* 7. Father's shirt size.

Question Title

* 8. Is this your first time attending Just Us

Yes

Other (please specify)

Question Title

* 9. Please list any issues or challenges that may interfere with your online experience (hearing loss, visual impairment, slow internet connection etc.)

Question Title

* 10. We may offer concurrent sessions for survivors and fathers. Do you and your child each have access to your own device?

Yes

Question Title

* 11. Do you have any goals or expectations for the retreat?

Question Title

* 12. Are there any topics you would like discussed at the retreat?

Question Title

* 13. Please describe 2-3 strengths in your relationship with your child (brain tumor survivor)

Question Title

* 14. Please describe 2-3 challenges in your relationship with your child (brain tumor survivor)

Question Title

* 15. Please describe one of your child's accomplishments or successes over the past year.

Question Title

* 16. Please list an emergency contact for you and your child (name, relationship and phone number)

Question Title

* 17. Do you or your child have any conflicts with the retreat (i.e. is there a window of time you will not be able to attend?).

Yes, we do have a conflict and cannot attend the entire retreat

No, we are able to attend the entire retreat

If yes, (please specify details of conflict)