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 your children with name, age, and birthdate (including birth year) *

Will friends or family members other than those listed above 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? *

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