Initial application

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? *

Email *

Phone Number *

How did you hear about The Still Place? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What County do you live in? *

Requested retreat dates *

Parental relationship *

Father's Name *

First

Last

Mother's Name *

First

Last

Other (partner) *

First

Last

List family members with names, age, and birthdates (including birth year) *

Will additional friends or family members will be coming? *

Yes No

If yes, who will be joining you and what is their relationship to your family? *

Tell us about your child's illness *

Which child/children are ill *

Have you experienced a Still Place Retreat in the past? *

Yes No

How long has it been since you had a family vacation? *

Hours worked each week *

Paid vacation/no paid vacation *

I agree to receiving marketing and promotional materials *

Submit

REST, RENEWAL and Re-creation

for families with seriously ill children

The Still Place, Inc. is a North Carolina registered 501(c)3 nonprofit organization
registered for solicitation in NC, FL and GA
FLORIDA SOLICITATION OF CONTRIBUTIONS ACT: LICENSE #CH57163:
A copy of the official registration and financial information may be obtained from the Division of Consumer Services by calling toll-free within the State of Florida. Registration does not imply endorsement, approval, or recommendation by the State of Florida.
Florida Division of Consumer Services
1-800-HELP-FLA (435-7352) www.FloridaConsumerHelp.com

FAMILY RETREAT INITIAL APPLICATION

REST, RENEWAL and Re-creation

Mailing Address: PO Box 31 Hayesville, NC, 28904