Family Applicant Information

Thank you for your interest in Rett's Roost Bereavement Retreat for parents that lost their only child. This retreat will take place in the lovely beach town of Ogunquit, ME. Please take time to fill out our application. You will be informed within one week of submitting whether you have been accepted to attend. Allow yourself 20 minutes to complete.

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* 1. Family Information

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

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

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* 8. Preferred gender of child no longer with you

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* 9. Birthday

Date / Time

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* 10. Date of Death

Date / Time

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

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