I understand that Respite Retreats programs are for cancer patients, their families and caregivers with a current cancer diagnosis or within 6 months of active treatment. By checking a box below I am confirming that I am eligible to participate in a Respite Retreats' Day Retreat.

I am a cancer patient, caregiver or family member of someone with a current cancer diagnosis.

I am a cancer patient, caregiver or family member of someone within 6 months of cancer treatment.

Please register me for the June 22 retreat (male cancer patients)

Please register me for the July 24 retreat (metastatic patients)

Please register me for the October 26 retreat

Patient Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Work Phone

(###)

###

####

Gender *

Male

Female

Other

Race *

African American

Asian

Caucasian

Hispanic

Native American

Other

Does the Patient Live Alone?

Yes

No

Marital Status

Single

Married

Divorced

Widowed

Has the patient participated in a retreat with Respite Retreats this year? *

This is for statistical purposes only and will not affect eligibility.

Yes

No

Date of Diagnosis

MM

DD

YYYY

Are you currently in treatment? *

Yes

No

Last treatment date? *

MM

DD

YYYY

Treatment *

Please check all that apply.

Surgery

Chemotherapy

Radiation

Other

Caregiver or family member attending the retreat with you.

First Name

Last Name

Date of Birth

MM

DD

YYYY

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Work Phone

(###)

###

####

Gender

Male

Female

Other

Race

African American

Asian

Caucasian

Hispanic

Native American

Other

Coordinator's Name

First Name

Last Name

Phone Number

(###)

###

####

I give Respite Retreats permission to contact my healthcare provider to verify my diagnosis and discuss any concerns they may have with me participating in this retreat.

I do NOT give Respite Retreats permission to contact my healthcare provider to verify my diagnosis and discuss any concerns they may have with me participating in this retreat.