Family Healing Retreat Health and Registration Form

Dates to be announced soon.

Cancer Survivor Information

First Name

Last Name

Nickname

Address

City

State/Province

Zip/Postal

Country

Email

Phone Number (Parent phone number if survivor is under 17)

Birthday (Month, Day, Year)

Age

Emergency Contact and Phone Number

Gender

Female

Male

Other

T-shirt Size?

Youth

Adult

T-shirt Size?

Parent Contact Information

Parent Names (Please type all adults over 18 years old here)

Address

City

State/Province

Zip/Postal

Country

Phone Number

Email (provide at least one)

Emergency contact name and phone # (someone not attending retreat)

Parent 1 Name

Parent 1 T-shirt Size?

Parent 2 Name

Parent 2 T-shirt Size?

Children Attending

Only children ages 5-17 please. If you have any questions, please contact us at (616) 847-0839.

Child 1 First Name

Child 1 Last Name

Child 1 Nickname

Child 1 Birthday (Month, Day, Year)

Child 1 Age

Child 1 Gender

Female

Male

Other

Child 1 T-Shirt Size?

Youth

Adult

Child 1 T-Shirt Size?

Child 2 First Name

Child 2 Last Name

Child 2 Nickname

Child 2 Birthday (Month, Day, Year)

Child 2 Age

Child 2 Gender

Female

Male

Other

Child 2 T-Shirt Size?

Youth

Adult

Child 2 T-Shirt Size?

Child 3 First Name

Child 3 Last Name

Child 3 Nickname

Child 3 Birthday (Month, Day, Year)

Child 3 Age

Child 3 Gender

Female

Male

Other

Child 3 T-Shirt SIze?

Youth

Adult

Child 3 T-Shirt Size?

Child 4 First Name

Child 4 Last Name

Child 4 Nickname

Child 4 Birthday (Month, Day, Year)

Child 4 Age

Child 4 Gender

Female

Male

Other

Child 4 T-Shirt Size?

Youth

Adult

Child 4 T-Shirt Size?

Survivor Profile

Type of Cancer

Year Diagnosed

Which stage?

1

2

3

4

Have you had any recurrence?

Yes

No

I don't know.

If you have had recurrence, please list the date:

Oncologist Name

Cancer Center

Have you received chemotherapy?

Yes

No

Are you currently in treatment?

Yes

No

Have you received radiation?

Yes

No

If you have received chemotherapy, what was the name of it?

Have you had any significant medical procedures? Please describe.

Are there other health concerns we should know about? (diabetes, heart condition, etc.)

Is there anything else relating to you cancer diagnosis that we should be aware of? (infection, neuropathy, etc.)

Do you have any food/ dietary restrictions? Include allergies.

How do you feel physically?

Please list your current medications including dosage and frequency.

Please list any medical equipment you are bringing with you such as a wheelchair, oxygen, walker, etc.

Do you have any physical limitations we should know about?

Photo Consent

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.

I agree.

I do not agree and decline.

Signature & Disclaimer

Please read the disclaimer and type the date and your name below as your signature.

I have completed the above information and acknowledge that the same is true. I acknowledge that I am a voluntary participant and I agree to assume responsibility for myself. I further agree to waive any claims against Bluebird Cancer Retreats, its officers, employees, agents or volunteers resulting from any and all losses, damages, costs and expenses that are caused by or arise out of any act, omission, default, negligence or other misconduct by Bluebird Cancer Retreats, Inc. in connection with this participation. I acknowledge that the Bluebird Cancer Retreats volunteers are not providing medical or psychological diagnosis, treatment, opinions, referrals, guidance, assistance, or counseling for me specifically, and that these volunteers are present for the purpose of facilitating involvement and not to provide professional services to group participants. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and that my emergency contact will be notified as soon as possible in case of an emergency. In the event they cannot be reached, I hereby authorize Bluebird Cancer Retreats to acquire medical treatment for me. Finally, I understand that all buildings and grounds are designated as no smoking areas.

Survivor Signature (unless under 18 yrs.)

Parent 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.

Family Name

Are there any health issues in your family that you would like to share with our staff?

Are you or anyone in your family currently participating in a support group? If so, please list the location and organization.

How has this cancer diagnosis affected your family dynamic?

What are you hoping to get out of your Bluebird experience?

Do you (or anyone in your family) have any fears or concerns about the retreat?

How did you hear about Bluebird Cancer Retreats?

Have you attended a Bluebird retreat in the past?

Please list anything else you would like to share with our staff.

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!