Little Pink Houses of Hope

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2021 Retreat Application

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Breast Cancer Applicant Information
Fields with asterisks (*) are required and must be filled in.
Name*
First Last
Street Address*
Address Line 2
City*
State / Province / Region*
Zip / Postal Code*
Country*
Email*
Mobile/Main Phone*
Date of Birth*
MM
DD
YYYY
Gender*
Being a male breast cancer patient. If a male only retreat became available, would you be interested in attending?*
T-Shirt Size*
Occupation
Employer
Breast Cancer Confirmation*
I confirm that I have been diagnosed with breast cancer and all answers I will give in this application regarding treatment and diagnosis will be related to my breast cancer diagnosis only.
- Yes
- No
We are sorry, you are not eligible to apply for a retreat.
Little Pink Houses of Hope serves only breast cancer patients at this time. We know anyone facing cancer deserves this type of vacation, but at the time we are only able to serve the breast cancer community.

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Retreat Information
Applications for individual retreats close approx. 3 months before start of retreat.
If a retreat has "CLOSED" next to the name, we are no longer accepting applications for that retreat at the time of your application.
Please note that the retreats listed are for the 2021 Retreat Season only.
2021 Retreat Dates*
Carefully consider your calendar, retreat location details & travel expense capabilities.
- April 24 - May 1, 2021 Carolina Beach, NC
- April 24 - May 1, 2021 St. John USVI (Couples Only)
- May 1-8, 2021 Scottsdale, AZ
- May 1-8, 2021 Topsail Island, NC
- May 8-15, 2021 Hatteras Island, NC
- June 5-12, 2021 Ocean City, MD
- June 5-12, 2021 Sedona, AZ
- June 12-19, 2021 Key West, FL
- June 12-19, 2021 Blue Ridge, GA
- August 14-21, 2021 Emerald Isle, NC
- August 21-28, 2021 Orange Beach, AL
- September 8-15, 2021 Manistee, MI (Couples Only)
- September 11-18, 2021 Grand Haven, MI
- September 11-18, 2021 Lake Tahoe, CA
- September 18-25, 2021 Oak Island, NC
- October 17-24, 2021 Buxton, NC (Couples only)
- October 17-22, 2021 Myrtle Beach, SC
- October 17-24, 2021 Central Coast California
- October 30 - November 6, 2021 New Smyrna Beach, FL
You have selected one of our couples retreats.*
Each couples retreat requires couples to share accommodations. You will be staying in a private bedroom with private bathroom, but will need to share common space with one or more other couples.
Because of shared accommodations, we require that a background check be done on each individual before coming on a couples retreat.
By selecting 'yes' below, you consent to a background check. If you do not wish to have a background check completed, please uncheck the couples retreat options above and this message will not appear.
- Yes
Additional Retreat Option:

Bringing HOPE Home - Virtual Weekend Retreat

Because of the prevailing COVID restrictions on travel and social distancing requirements, Little Pink has created an at-home virtual mini-retreat from the safety of your own home. We have selected the best parts of our signature retreat and are "Bringing HOPE Home" to you and your family. You can expect surprise packages with fun activities, connection via ZOOM with other families on the breast cancer journey, and lots of laughter and love!
Please choose if you would be interested in attending our "Bringing HOPE Home" Retreat*
Travel Confirmation*
I understand that if selected for a retreat, my family is responsible for any cost associated with traveling to, from and during the retreat location.
- Yes
- No
We are sorry, you are not eligible to apply for a retreat.
Each family is responsible for getting to the retreat location if they are selected to attend. Little Pink Houses of Hope does not assist in any way with cost associated with getting to the retreat location or transportation during the retreat week.

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Breast Cancer Information
Date of Initial Breast Cancer Diagnosis*
MM
DD
YYYY

This does not have to be an exact day. Month and Year are most important.
Your age at Initial Diagnosis*
_______________________________________________________
Type(s) and/or characteristics of your Breast Cancer:*
Check all that apply.
- IBC
- HER2+
- ER+
- PR+
- Triple Negative
- Triple Positive
- Metastatic
- Other
- Not Sure
Current Stage of Breast Cancer*
- Stage 0
- Stage 1
- Stage 2
- Stage 3
- Stage 4
Other Breast Cancer Type*
Date of Diagnosis of Metastasis*
MM
DD
YYYY
_______________________________________________________
Medical Treatments, Surgeries and Procedures - Select Past and Future*
In regards to your Breast Cancer diagnosis only.
- None
- Chemotherapy
- Radiation
- Removal of Cancer Surgery
- Maintenance Hormone Therapy
- Nontraditional Alternative Therapies
- Reconstruction Surgery
Date of Last Chemotherapy*
Date Format: MM slash DD slash YYYY

This can be a future date. Exact day can be an estimate.
Date of Last Radiation*
Date Format: MM slash DD slash YYYY

This can be a future date. Exact day can be an estimate.
Date of Last Cancer Removal Surgery*
Date Format: MM slash DD slash YYYY

This can be a future date. Exact day can be an estimate.
Date of Last Additional Hormone Therapy*
Date Format: MM slash DD slash YYYY

This can be a future date. Exact day can be an estimate.
Date of Last Reconstruction Surgery*
Date Format: MM slash DD slash YYYY

This can be a future date. Exact day can be an estimate.

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Medical Doctor and Facility Information
Breast Cancer Oncologist Name*
First Last
Medical Facility Name*
Oncologist Street Address*
Address Line 2
City*
State / Province / Region*
Zip / Postal Code*
Country*
Oncologist Phone*
_______________________________________________________

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Help us get to know you better!
Rate your areas of stress*
None Low Medium High Max
Finances
Partner relationship
Children relationships
Fear of reoccurance
Work
Fear of dying
Lack of family/friend support
COVID-19
Your Story*
What would this retreat mean to your family? Our assignment committee reads every application to help in deciding what families to place in our retreat program. Maximum of 1000 characters.

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Family Member Information
Please only include immediate Family or Caregiver(s). Our retreats are designed to serve the patient, spouse/partner or primary caregiver and immediate family living in the home.
Number of family members - NOT INCLUDING YOU.*
Please enter the number of eligible person(s) you would like to attend the retreat with you.
Please enter a number from 0 to 8.
_______________________________________________________
Please name your spouse, partner or caregiver in the first slot if they will be attending the retreat with you.
Additional Person 1 Name*
First Last
Additional Person 1 Cell Phone
Additional Person 1 Birthday*
MM
DD
YYYY
Additional Person 1 Current Age*
If less than 1, enter 0.
Additional Person 1 Gender*
T-Shirt Size
Additional Person 1 Relationship to YOU.*
Additional Person 1 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 1_________
Additional Person 2 Name*
First Last
Additional Person 2 Birthday*
MM
DD
YYYY
Additional Person 2 Current Age*
If less than 1, enter 0.
Additional Person 2 Gender*
T-Shirt Size
Additional Person 2 Relationship to YOU.*
Additional Person 2 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 2_________
Additional Person 3 Name*
First Last
Additional Person 3 Birthday*
MM
DD
YYYY
Additional Person 3 Current Age*
If less than 1, enter 0.
Additional Person 3 Gender*
T-Shirt Size
Additional Person 3 Relationship to YOU.*
Additional Person 3 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 3_________
Additional Person 4 Name*
First Last
Additional Person 4 Birthday*
MM
DD
YYYY
Additional Person 4 Current Age*
If less than 1, enter 0.
Additional Person 4 Gender*
T-Shirt Size
Additional Person 4 Relationship to YOU.*
Additional Person 4 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 4_________
Additional Person 5 Name*
First Last
Additional Person 5 Birthday*
MM
DD
YYYY
Additional Person 5 Current Age*
If less than 1, enter 0.
Additional Person 5 Gender*
T-Shirt Size
Additional Person 5 Relationship to YOU.*
Additional Person 5 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 5_________
Additional Person 6 Name*
First Last
Additional Person 6 Birthday*
MM
DD
YYYY
Additional Person 6 Current Age*
If less than 1, enter 0.
Additional Person 6 Gender*
T-Shirt Size
Additional Person 6 Relationship to YOU.*
Additional Person 6 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 6_________
Additional Person 7 Name*
First Last
Additional Person 7 Birthday*
MM
DD
YYYY
Additional Person 7 Current Age*
If less than 1, enter 0.
Additional Person 7 Gender*
T-Shirt Size
Additional Person 7 Relationship to YOU.*
Additional Person 7 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 7_________
Additional Person 8 Name*
First Last
Additional Person 8 Birthday*
MM
DD
YYYY
Additional Person 8 Current Age*
If less than 1, enter 0.
Additional Person 8 Gender*
T-Shirt Size
Additional Person 8 Relationship to YOU.*
Additional Person 8 Other Relationship to YOU.*
_________END ADDITIONAL PERSON 8_________

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Additional Family Information
1. Do you or any of your family members have allergies? Food or environmental.*
This information does not affect acceptance.
Please explain details about allergies. Food or environmental.*
Information to help us get to know and serve your family better.
_______________________________________________________
2. Do you or any of your family members have non-allergy food restrictions?*
This information does not affect acceptance.
Please explain details about non-allergy food restrictions or require a special diet?*
Information to help us get to know and serve your family better.
_______________________________________________________
3. Do you or any of your family members have social or physical limitations?*
This information does not affect acceptance.
Please explain details about physical or social limitations.*
Information to help us get to know and serve your family better.
_______________________________________________________
4. Can you and all members of your family climb stairs?*
This information does not affect acceptance.
Please explain details about stairs*
Information to help us get to know and serve your family better.
_______________________________________________________
5. Do you or anyone attending the retreat with you use or need a wheelchair?*
This information does not affect acceptance.
Please explain wheelchair use and/or needs*
Information to help us get to know and serve your family better.
_______________________________________________________
6. Is there anything else you would like to tell us about you or your family members attending?
Any information to help us get to know and serve your family better. This could include special interests or talents.

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Emergency Contact Information
Please provide an emergency contact that will NOT be attending the retreat. We cannot process your application without this information.
Emergency Contact Name*
First Last
Emergency Contact Street Address*
Address Line 2
City*
State / Province / Region*
Zip / Postal Code*
Country*
Emergency Contact Mobile / Main Phone*
Emergency Contact Email*
Emergency Contact Relationship to Applicant*

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Statistical Information
To assist us with future program development and funding, please complete the following fields. Your answers below will NOT be used in our selection process.
How did you hear about Little Pink?*
This information does not affect acceptance.
- Social Media
- Blog
- Doctor/Hospital
- Conference
- Website/Internet Search
- Friend
- Someone that attended a retreat previously
- I do not wish to answer
- Other
How did you hear 'other'?*
_______________________________________________________
Are you concerned about the additional stress of your cancer diagnosis on your family?*
Yes No I do not wish to answer
_______________________________________________________
Total Household Income*
This information does not affect acceptance.
- $0 to $50,000 per year
- $50,001 to $100,000 per year
- $100,001 to $150,000 per year
- $150,000 per year or more
- I do not wish to provide this information
_______________________________________________________
Ethnicity*
This information does not affect acceptance.
- African American or Black
- Asian or Pacific Islander
- Caucasian
- Latino
- Multiracial
- Native American
- Other
- I do not wish to provide this information
_______________________________________________________
Signature
Retreats are designed to serve the patient, spouse or primary caretaker and immediate family living in the home. By printing my name below, I state that the foregoing information is complete and accurate to the best of my knowledge.
Print Name*
First Last