Survivor/Caregiver Retreat Health and Registration Form

This retreat is for the survivor plus a support person. This can be a friend, spouse, family member, caregiver, etc. over the age of 18.

Which retreat would you like to attend?

May 19 - 21, 2023

October 20 - 22, 2023

First Name

Last Name

Nickname

Address

City

State/Province

Zip/Postal

Country

Email

Phone

Emergency Contact and Phone Number

Birthday (Month, Day, Year)

Age

Gender

Female

Male

Other

Caregiver Information

A caregiver can be your spouse, friend, family member, support person, etc. The couples retreat allows you to bring your caregiver with you so that they can be pampered as well.

Caregiver First Name

Caregiver Last Name

Nickname

Caregiver Birthday (Month, Day, Year)

Caregiver Age

Caregiver Address

City

State/Province

Zip/Postal

Country

Caregiver Phone Number

Caregiver Email

Please list any dietary restrictions AND allergies here:

Relationship to Cancer Survivor

Diagnosis and Treatment

Type of Cancer

Year Diagnosed

Which stage?

1

2

3

4

Any recurrence?

Yes

No

Date of recurrence, if any:

Oncologist Name

Cancer Center

Have you received chemotherapy?

Yes

No

Are you currently in treatment?

Yes

No

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

Have you received radiation?

Yes

No

Are you currently receiving radiation?

Yes

No

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

Have you received oral chemotherapy?

Yes

No

Are you currently receiving oral chemotherapy?

Yes

No

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

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? Do you need assistance with stairs?

Have you been fully vaccinated for COVID-19?

Yes

No

Has your caregiver been fully vaccinated for COIVD-19?

Yes

No

Do you snore?

Yes

No

I don't know.

Are you a light sleeper?

Yes

No

I don't know.

Photo Consent

Please check the box as your signature to agree to the following statement below.

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 decline to have my photo used in any capacity.

Signature and Disclaimer

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

Please 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."

Health and Holistic Therapy Questionnaire

As part of your retreat experience, emotional and physical pampering opportunities may be available. The following information will be given to volunteer practitioners and our staff for your protection and to allow them to best serve you. This is required for all attendees.

Do you have any health issues you would like to share with the practitioners? Please list any sensitive areas on your body that a practitioner should not touch.

Has your doctor warned you against having deep tissue massage or other body work?

Yes

No

Other

Do you have a history of blood clots?

Yes

No

Other

If you have had a blood clot, please list the location.

Have you tried any alternative forms of therapy during your cancer journey? (Massage, healing touch, chiropractic, etc.)

Yes

No

I don't know.

If you have tried an alternate form of therapy, please describe it here:

Consent for Therapy

Please type the date and your signature below after you read the consent for holistic therapy.

"I understand that therapeutic massage services are designated to be a health aid and are in no way meant to take the place of a physician’s care. Any information exchanged during massage session(s) is educational in nature and is intended to help me become more familiar with and conscious of my own health status."

Emotional Care Questionnaire

Are you currently in a cancer support group?

Yes

No

If you are in a cancer support group, where is it located and which organization is it through?

Who/what are the major sources of support in your life?

Do you feel you are receiving enough support in your life currently?

Yes

No

Sometimes

I don't know.

What are the biggest stressors in your life?

Do you have an escape from these stressors? Please list what it is.

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

Please list any fears or concerns you have about the retreat.

How did you hear about Bluebird Cancer Retreats?

Have you attended a Bluebird retreat in the past?

Caregiver Health and Holistic Therapy Questionnaire

As part of your retreat experience, emotional and physical pampering opportunities may be available. The following information will be given to volunteer practitioners and our staff for your protection and to allow them to best serve you. This is required for all attendees.

Do you have any health issues you would like to share with the practitioners? Please list any sensitive areas on your body that a practitioner should not touch.

Has your doctor warned you against having deep tissue massage or other body work?

Yes

No

Other

Do you have a history of blood clots?

Yes

No

Other

If you have had a blood clot, please list the location.

Consent for Therapy

Please type the date and your signature below after you read the consent for holistic therapy.

"I understand that therapeutic massage services are designated to be a health aid and are in no way meant to take the place of a physician’s care. Any information exchanged during massage session(s) is educational in nature and is intended to help me become more familiar with and conscious of my own health status."

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!