Retreat Registration

Name *

First

Last

Mobile Number *

Home Phone Number

Email *

Address *

City *

State *

Zip Code *

T-shirt Size *

Age *

Birthdate *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

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?

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: *

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

What 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 *