Grief is Love Online Retreat Application

Applicants' Information

Thank you for your interest in Rett's Roost Bereavement Retreats. Because of the COVID-19 Crisis, we have had to move these one day retreats to an online format. Instead of meeting for one day in person, we will have two online meetings 2 weeks apart. Please take time to fill out our application. You will be informed within 1 week 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. Which bereavement retreat are you applying for:

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* 2. Family Information

Family Surname(s) *

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code

Country *

Email Address *

Phone Number *

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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. Emergency Contact Information (cannot be on retreat)

Name *

Relationship

Email Address *

Phone Number *

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* 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)

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

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* 10. Preferred gender of child no longer with you

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* 11. Birthday

Date / Time

Date

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* 12. Date of Death

Date / Time

Date