(back up)Bereavement Retreat Initial Application

Bereavement Retreat Initial Application

* Indicates required field

Name *

Phone *

Email Address *

Address *

County *

Name and birthdays of Family members: *

Occupation of first two: *

Relationship status: *

Name of your child who passed away: *

Date of your Child’s Birth: *

Date of your Child’s Loss: *

Diagnosis or Cause of death: *

What are your biggest challenges to coming to a retreat? *

Do you have any concerns about coming to this remote location? *

Do you have any mobility or medical issues we need to know about? *

We offer an additional night stay for you to relax, unwind and process. Are you interested in staying an additional night after the retreat *

I will need to leave as soon as the event ends I would like to spend the night after the retreat attends I would like to stay a full day and night after the retreat ends

Would your family be interested in coming for a family retreat at The Still Place? *

Yes No Maybe

Is there anything additional that you would like us to know about you, your family or child? *

Is there anything that might hinder your ability to come such as finances, time off for work, child care. If so, please feel free to share with us. *

Is travel assistance required for you to attend a retreat? *

Yes, I can't come without travel assistance, It would be helpful but not required I do not need travel assistance to attend

Submit

​​Bereavement Retreat Initial Application

Mailing Address: PO Box 31 Hayesville, NC 28904

Bereavement Retreat Initial Application