Forever Healing Family Bereavement Retreat Application

Family Applicant Information

Thank you for your interest in Rett's Roost Forever Healing Bereavement Retreat for families that experienced the sudden loss of a child under 18. This retreat will take place in Ogunquit, ME on August 20-23, 2020. 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.

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* 1. Family Information

Family Name(s) *

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code

Country *

Email Address *

Phone Number *

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

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

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* 4. Additional Email Address for Communications:

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* 5. Additional Phone Number for Communications:

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

Name *

Relationship

Email Address *

Phone Number *

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* 7. 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)

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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

Date

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* 11. Date of Death

Date / Time

Date

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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

Date

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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

Date

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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

Date

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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

Date