Open to Healing Retreats

Application & Release Forms

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Parent or guardian 1: ______

Email:______Phone:______

Parent or guardian 2: ______

Email:______Phone:______

Child’s name lost to cancer: ______

Gender (optional): ______

Birthday: ______Angelversary:______

Sibling 1: ______

Gender (optional):______Birthday:______

Sibling 2: ______

Gender (optional):______Birthday:______

Sibling 3: ______

Gender (optional):______Birthday:______

Contact Address:______

______

______

Emergency Contact not on Retreat: ______

Relation:______Phone:______

Currently we can only accept families of 5, including 2 guardians and 3 siblings or other children you care for. This is so that we have room for multiple families to attend (our bed space is limited—the intimate nature of our retreats are what makes Rett’s Roost unique). Thank you for understanding this policy.

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Acceptance Protocol:

In order for your family to be accepted to attend a Rett’s Roost retreat, you and your child(ren) must be in good general health.A parent or guardian attending the retreat must complete to the best of their knowledge all pages of this application.Please send to the following email or USPS mailing address:

Rett’s Roost

5 Roe Fields Dr

South Berwick, ME 03908

Questions?: Call Deana at 508-813-9222

You will receive an email confirmation within 24 hours of application receipt that you have been accepted to attend or added to our waiting list.

Cancellation Policy:

We completely understand that medical situations may arise where you need to cancel at the last minute. However, this retreat is only offered to a small group of people. There will likely be a waiting list and we want to make sure that the next family on that list gets to come if your family needs to back out. Therefore, we would greatly appreciate being notified as soon as possible if you will not be able to attend.

Deposit Policy:

We ask for a deposit of $150 per family for this retreat that will be refunded to you after the retreat or if you need to cancel because of a serious medical or family situation. If this is a financial burden, please let us know. Deposits can be made via check or as a donation:

Travel Grants:

For families traveling from outside New England and New York, we may be able to offer support. We can offer a travel scholarship to at least one family per retreat. If you are interested in this, please contact us at .

Liability Release:

By completing this application and signing below you have acknowledged that there is somerisk involved with the activities provided ata Rett’s Roost retreat. With your signature below, you are releasing Rett’s Roost, and any volunteer or staff present at the retreat from any liability. This includes, but is not limited to; 1. Any bodily injury that may occur to yourself or any minor in your company & 2. Loss or damage done to personal possessions you have brought with you during the retreat weekend.

Parent/Guardian Print Name: ______

Signature: ______Date: ______

Immunizations:

I confirm that my child(ren)under 26 have been immunized based on the CDC recommendations for their age and I possess copies of the record of vaccinationsfor Rett’s Roost’s approval. These forms are either attached to this application, or I will bring them with us on the opening day of retreat.

Parent/Guardian Print Name: ______

Signature: ______Date: ______

Photo/Video Release:

On behalf of myself and my family, I do hereby give Rett’s Roost, without consideration or compensation, permission to use photographs and/or videotape that may be taken or recorded while my child and family are attending the retreat for promotional, educational, or fundraising activities including social media. It is my understanding that these likenesses may be used to promote public and professional understanding and support of the program. I waive any right that I may have to inspect or approve the finished product or the use to which it may be applied.

Parent/Guardian Print Name: ______

Signature: ______Date: ______

Joining our Community of Families:

Are you willing to provide us with a write-up of your family’s cancer story and a photo for our website? It’s totally ok to say no.

The Perfect Programming

Please circle your families interest level, 5=very interested, 1=not at all interested, 0=not sure:

Individual Grief Support012345

Nature activity012345

Yoga & Meditation012345

Writing workshop012345

Healthy living workshop012345

Arts & Crafts012345

Animal Interactions012345

Massage/Reiki012345

Group Grief Support012345

Meet with a Medium012345

Family Portrait Session012345

Downtime to relax012345

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The SeriousStuff…

  • Please tell us a little about your child’s cancer diagnosis and treatment and passing includingimportant dates:
  • What has been the most difficult part of the grieving process for you and your family?
  • What have been the most helpful aspects of your grieving process? If you are not sure, it is okay to leave this blank.
  • Is there anything that makes you or your children nervous, unhappy, or upset?
  • Please list any non-food allergies or medical conditions we should be aware of:

Nom, nom, nom…

  • Favorite Foods:
  • No thank you Foods:
  • Allergy Foods:

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