ABOUT US
OUR MISSION, VISION AND VALUES
Our Story
Staff
Gnorman and Gnorma Gnome
Board of Directors
Monthly Newsletters
Founders
>
Dr. Dawn
Dr. Craig
Corporate and Community Partners
Annual Reports
DONATE
Give
WISH LIST
Volunteer
Volunteer Team Page
Teen Volunteers (YEP)
RETREATS
A TYPICAL FAMILY RETREAT
Still Life Virtual Retreats
Tour The House and View the Schedule on VRBO
PAY-IT-FORWARD VACATION
Bereavement Retreat
STORE
CONTACT US
Family Retreat Initial Application
Family Retreat Forms
Host Family Application
Bereavement Retreat Registration
Sign Up for Newsletter
ABOUT US
OUR MISSION, VISION AND VALUES
Our Story
Staff
Gnorman and Gnorma Gnome
Board of Directors
Monthly Newsletters
Founders
>
Dr. Dawn
Dr. Craig
Corporate and Community Partners
Annual Reports
DONATE
Give
WISH LIST
Volunteer
Volunteer Team Page
Teen Volunteers (YEP)
RETREATS
A TYPICAL FAMILY RETREAT
Still Life Virtual Retreats
Tour The House and View the Schedule on VRBO
PAY-IT-FORWARD VACATION
Bereavement Retreat
STORE
CONTACT US
Family Retreat Initial Application
Family Retreat Forms
Host Family Application
Bereavement Retreat Registration
Sign Up for Newsletter
FAMILY RETREAT INITIAL APPLICATION
If you or someone you know would like to apply for a
Still Place
Family Retreat, please fill out the fields below.
*
Indicates required field
Who is filling out this application?
*
First
Last
What is your relationship in the family?
*
Parent
Other
Email
*
Phone Number
*
Please share a phone number where you can receive text messages if possible.
How did you hear about The Still Place?
*
Facebook/Support Group
Ansley's Rainbows of Hope
Past TSP family
Other...
Address
*
Line 1
Line 2
City
State
Zip Code
Country
What county do you live in?
*
Requested retreat dates
*
We offer full week retreats. Sunday evening to Sunday morning (ideally). Please share 3 different weeks that will fit your schedule. We will be in touch!
Parental Relationship
*
Married
Single
Shared parenting
Foster
Adoptive Relationship
Strains/challenges
Father's Name
*
First
Last
Mother's Name
*
First
Last
Other (partner)
*
First
Last
Relation to You
*
List all children's name, birthdate, and gender.
Child's Name
*
Child's Birthdate
*
Child's Gender
*
Male
Female
Child's Name
*
Child's Birthdate
*
Child's Gender
*
Male
Female
Child's Name
*
Child's Birthdate
*
Child's Gender
*
Male
Female
Child's Name
*
Child's Birthdate
*
Child's Gender
*
Male
Female
Child's Name
*
Child's Birthdate
*
Child's Gender
*
Male
Female
Child's Name
*
Child's Birthdate
*
Child's Gender
*
Male
Female
Will friends or family members other than those listed above be coming?
*
Yes
No
If yes, please list those that will be joining you and what is their relationship to your family?
Guest Name
*
Relation to You
*
Age (DOB) if child
*
Guest Name
*
Relation to You
*
Age (DOB) if child
*
Guest Name
*
Relation to You
*
Age (DOB) if child
*
Guest Name
*
Relation to You
*
Age (DOB) if child
*
Tell us about your child's illness
*
Tell us the name of your child's illness. We will cover details in your family interview.
Which child/children are ill?
*
If you have more than one child in your family with an illness, please let us know which child has which illness so we can know how to make your retreat the best it can be for each of them.
What type of medications is your child on?
*
Do you need any special equipment at the house (e.g., wheelchair ramp, walker, etc.)
*
Are there other family members with medical problems we should be aware of?
*
Does anyone in your family have any physical limitations?
*
How long has it been since you had a family vacation?
*
Hours worked each week
*
Paid vacation/No paid vacation
*
Have you experienced a Still Place Retreat in the past?
*
Yes
No
I agree to receiving marketing and promotional materials
*
Submit
