Family Applicant Information

Thank you for your interest in Rett's Roost Bereavement Retreats. This year all bereavement retreats will take place in the lovely beach town of Ogunquit, ME. Please take time to fill out our application. You will be informed within 48 hours of submitting whether you have been accepted to attend. Allow yourself 20 minutes to complete.

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* 2. Family Information

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

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

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* 5. Additional Email Address for Communications:

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* 6. Additional Phone Number for Communications:

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

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

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* 9. Preferred gender of child no longer with you

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* 10. Birthday

Date / Time

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* 11. Date of Death

Date / Time

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* 12. Sibling (a):

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* 13. Preferred Gender of child a

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* 14. Birthday of child a

Date / Time

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* 15. Sibling (b):

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* 16. Preferred gender of child b

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* 17. Birthday of child b

Date / Time

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* 18. Sibling (c):

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* 19. Preferred gender of child c

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* 20. Birthday of child c

Date / Time

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* 21. Sibling (d):

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* 22. Preferred gender of child d

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* 23. Birthday of child d

Date / Time

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

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