Family Healing Retreat Health and Registration Form
Dates to be announced soon.
Cancer Survivor Information
Parent Contact Information
Only children ages 5-17 please. If you have any questions, please contact us at (616) 847-0839.
Have you had any recurrence?
Have you received chemotherapy?
Are you currently in treatment?
Have you received radiation?
How do you feel physically?
Please read and type the date and your name below as your signature.
I hereby grant to Bluebird Cancer Retreats its agent or assigns, my permission to use my first name, any and all pictures, photographs of or news stories about me for reproduction in any form for, but not limited to, advertising, illustration, television, or scientific publication.
Signature & Disclaimer
Please read the disclaimer and type the date and your name below as your signature.
Emotional Care Questionnaire
As part of your retreat experience, emotional and physical pampering opportunities may be offered. The following information will be provided to our staff to better understand your needs.
Please hit submit and wait to receive an email or call confirmation. We primarily serve local West Michigan residents first, then open up our offerings to other locations. Thank you!