One & Only Child Loss Retreat Application

Family Applicant Information

Thank you for your interest in Rett's Roost Bereavement Retreat for parents that lost their only child. This year, the One & Only Bereavement Retreat will take place in the lovely beach town of Ogunquit, ME, Nov 6-9. Please take time to fill out our application. You will be informed within one week of submitting whether you have been accepted to attend. If you do not hear from us in that time, please contact us 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