Open to Healing Retreats
Application & Release Forms
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:
_________________________________________________________
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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.
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:
[email protected]
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.
2
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:
http://www.rettsroost.org/help-us-fly/donate/
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 [email protected] .
3
Liability Release:
By completing this application and signing below you have
acknowledged that there is some risk involved with the activities
provided at a 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 vaccinations for 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.
4
Parent/Guardian Print Name:
___________________________________________
Signature: __________________________________________ Date:
_____________
5
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 Support
0
1
2
3
4
1
2
3
4
5
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
5
Nature activity
0
Yoga & Meditation
5
Writing workshop
5
Healthy living workshop
5
Arts & Crafts
0
1
2
3
4
5
Animal Interactions
0
1
2
3
4
5
Massage/Reiki
0
1
2
3
4
5
Group Grief Support
0
1
2
3
4
5
Meet with a Medium
0
1
2
3
4
5
Family Portrait Session
0
1
2
3
4
5
0
1
2
3
4
Downtime to relax
5
6
7
The Serious Stuff…

Please tell us a little about your child’s cancer diagnosis and
treatment and passing including important 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?
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
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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