Family Applicant Information

Thank you for your interest in Rett's Roost Retreats. This year's Positively Healing Survivor retreats will be at Duck Puddle Campground in the lovely mid-coast town of Nobleboro, ME May 15-17, 2020 and hopefully a second at Shilo Farm in Eliot, ME Nov 6-9, 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 do not receive an email, please contact us at rettsroost@gmail.com. Allow yourself 20 minutes to complete this application.

Question Title

Image

Question Title

* 1. Family Information

Question Title

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

Question Title

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

Question Title

* 4. Additional Email Address for Communications:

Question Title

* 5. Additional Phone Number for Communications:

Question Title

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

Question Title

* 7. Please share the name of your child that had/has cancer:

Question Title

* 8. Preferred gender of your child with cancer

Question Title

* 9. Birthday

Date

Question Title

* 10. Date of Diagnosis

Date

Question Title

* 11. Type of primary cancer (include stage or risk level if applicable)

Question Title

* 12. Sibling (a):

Question Title

* 13. Preferred Gender of child a

Question Title

* 14. Birthday of child a

Date

Question Title

* 15. Sibling (b):

Question Title

* 16. Preferred gender of child b

Question Title

* 17. Birthday of child b

Date

Question Title

* 18. Sibling (c):

Question Title

* 19. Preferred gender of child c

Question Title

* 20. Birthday of child c

Date

Question Title

* 21. Sibling (d):

Question Title

* 22. Preferred gender of child d

Question Title

* 23. Birthday of child d

Date

Question Title

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

( Privacy & Cookie Notice

T