Please check one
I understand that this retreat is for those who have had or have a kidney cancer diagnosis, their caregivers and family members.
By checking a box below, I am confirming that I am eligible to participate in this Respite Retreats, in partnership with the Kidney Cancer Association's, Virtual Retreat.
Name
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
County
*
Age
*
Home Phone
(###)
###
####
Mobile Phone
(###)
###
####
Work Phone
(###)
###
####
Email
*
Gender
*
Race
*
Are you a veteran?
Does the Patient Live Alone?
Marital Status
Number of Dependent Children
Occupation
Is there anything else you think we should know?
Type of Cancer
Stage
Date of Diagnosis
MM
DD
YYYY
Are you currently in treatment?
Last treatment date?
MM
DD
YYYY
Treatment
Please check all that apply.
Name 1
First Name
Last Name
Date of Birth
MM
DD
YYYY
Address 1
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Mobile Phone
(###)
###
####
Work Phone
(###)
###
####
Email
Gender
Age
Race
Are you a veteran?
Relationship to Patient
Is there anything else you think we should know?
Hospital/Center Providing Cancer Treatment
Coordinator's Name
First Name
Last Name
Phone Number
(###)
###
####
Email
How did you hear about this retreat?
Name of referring hospital/treatment center/physician?
Thank you for registering for a virtual day retreat. We look forward to refueling your spirit.
We will be in touch soon with more details. Feel free to reach out with any question. We can be reached at contact@respiteretreats.org or by calling 410-988-5760.
The Respite Retreats Team
