Please enable JavaScript in your browser to complete this form.Name *FirstLastMobile Number *Home Phone NumberEmail *Address *City *State *Zip Code *T-shirt Size *SmallMediumLargeX-LargeXX-LargeAge *Birthdate *Emergency Contact Name *Emergency Contact Relationship *Emergency Contact Phone Number *Occupation (Current or Previous)Work *Full TimePart timeUnemployedRetiredMarital Status *SingleMarriedDivorcedWidowedCommitted RelationshipChildren *YesNoHow many?Ages?Date of Cancer Diagnosis *Type of Cancer *Surgery? *YesNoChemotherapy? *YesNoRadiation? *YesNoDate treatment completedIf Breast Cancer: reconstruction?YesNoAre 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 *Submit