Family Applicant Information

Thank you for your interest in Rett's Roost Retreats. This year's Positively Healing Survivor retreat will be back at Duck Puddle Campground in the lovely mid-coast town of Nobleboro, ME May 10-12, 2019. Please take time to fill out our application. You will be informed within 48 hours 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 had/has cancer:

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* 8. Preferred gender of your child with cancer

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* 9. Birthday

Date / Time

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* 10. Date of Diagnosis

Date / Time

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

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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

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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

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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

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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

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

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