Retreat Registration

Thank you for your interest in a Mighty Waters retreat.

Please fill out the form below. After you submit the form, you should see a confirmation message. We will reach out to you to confirm your registration.

Basic Information

Name *

First

Last

Mobile Number *

Home Number

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

T-shirt Size *

Birthdate *

Age *

Emergency Contact

Emergency Contact Name *

Relationship *

Phone Number *

Additional Information

Occupation (Current or Previous)

Work *

Marital Status *

Children *

How many?

Ages?

Date of Cancer Diagnosis *

Type of Cancer *

Surgery? *

Chemotherapy? *

Radiation? *

Date Treatment Completed

If Breast Cancer, reconstruction?

Reconstruction completed?

Date Reconstruction Completed

Are you facing any other physical or emotional health challenges? If so, please describe: *

Are you taking any medications related to cancer treatment or other conditions? If so, please list: *

Do you have any life-threatening allergies? If so, please list: *

What other challenges have you faced in your recovery? *

Have you experienced any other major life events that are affecting you now? *

What goals/expectations do you have for the Mighty Waters retreat? *

Do you have any dietary restrictions (Vegan, Vegetarian, other)? *

Do you have any special requests or concerns?

Do you require any wheelchair or other accommodations? If so, please explain:

How, or from whom, did you learn of Mighty Waters? Please be specific. *

Any other information you would like to include so that we may make your stay with us more comfortable?

Guest Signature *

Please note that typing your name in this box serves as an electronic signature.

Date *

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