Open to Healing Family Retreat Application

Family Applicant Information

Thank you for your interest in Rett's Roost Bereavement Retreats. Both Open to Healing Bereavement retreats will take place in the lovely beach town of Ogunquit, ME Aug 20-23 *RESCHEDULED FROM JUNE* (young children) and July 23-26 (older children). Please take time to fill out our application. You will be informed within 72 hours of submitting whether you have been accepted to attend. If you don't hear from us, feel free to check in at rettsroost@gmail.com. Allow yourself 20 minutes to complete.

Question Title

* 1. Which bereavement retreat are you applying for:

Question Title

* 2. Family Information

Family Name(s) *

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code

Country *

Email Address *

Phone Number *

Question Title

* 3. Name of parent or guardian (a):

Question Title

* 4. Name of parent or guardian (b):

Question Title

* 5. Additional Email Address for Communications:

Question Title

* 6. Additional Phone Number for Communications:

Question Title

* 7. Emergency Contact Information (cannot be on retreat)

Name *

Relationship

Email Address *

Phone Number *

Question Title

* 8. Which race/ethnicity best describes your family? (Choose all that apply)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

Question Title

* 9. Please share the name of your child that died:

Question Title

* 10. Preferred gender of child no longer with you

Question Title

* 11. Birthday

Date / Time

Date

Question Title

* 12. Date of Death

Date / Time

Date

Question Title

* 13. Sibling (a):

Question Title

* 14. Preferred Gender of child a

Question Title

* 15. Birthday of child a

Date / Time

Date

Question Title

* 16. Sibling (b):

Question Title

* 17. Preferred gender of child b

Question Title

* 18. Birthday of child b

Date / Time

Date

Question Title

* 19. Sibling (c):

Question Title

* 20. Preferred gender of child c

Question Title

* 21. Birthday of child c

Date / Time

Date

Question Title

* 22. Sibling (d):

Question Title

* 23. Preferred gender of child d

Question Title

* 24. Birthday of child d

Date / Time

Date