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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.
  • 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.
  • 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.
  • Carefully consider your calendar, retreat location details & travel expense capabilities.
  • 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.
  • 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!

  • 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.
  • 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

  • This does not have to be an exact day. Month and Year are most important.
  • _______________________________________________________
  • Check all that apply.
  • _______________________________________________________
  • In regards to your Breast Cancer diagnosis only.
  • Date Format: MM slash DD slash YYYY
    This can be a future date. Exact day can be an estimate.
  • Date Format: MM slash DD slash YYYY
    This can be a future date. Exact day can be an estimate.
  • Date Format: MM slash DD slash YYYY
    This can be a future date. Exact day can be an estimate.
  • Date Format: MM slash DD slash YYYY
    This can be a future date. Exact day can be an estimate.
  • 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

  • _______________________________________________________
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  • Help us get to know you better!

  • NoneLowMediumHighMax
    Finances
    Partner relationship
    Children relationships
    Fear of reoccurance
    Work
    Fear of dying
    Lack of family/friend support
    COVID-19
  • 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.
  • 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.
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 1_________
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 2_________
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 3_________
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 4_________
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 5_________
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 6_________
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 7_________
  • If less than 1, enter 0.
  • _________END ADDITIONAL PERSON 8_________
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  • Additional Family Information

  • This information does not affect acceptance.
  • Information to help us get to know and serve your family better.
  • _______________________________________________________
  • This information does not affect acceptance.
  • Information to help us get to know and serve your family better.
  • _______________________________________________________
  • This information does not affect acceptance.
  • Information to help us get to know and serve your family better.
  • _______________________________________________________
  • This information does not affect acceptance.
  • Information to help us get to know and serve your family better.
  • _______________________________________________________
  • This information does not affect acceptance.
  • Information to help us get to know and serve your family better.
  • _______________________________________________________
  • 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.
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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.
  • This information does not affect acceptance.
  • _______________________________________________________
  • YesNoI do not wish to answer
  • _______________________________________________________
  • This information does not affect acceptance.
  • _______________________________________________________
  • This information does not affect acceptance.
  • _______________________________________________________
  • 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.
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