Grief and Loss Workshops at Harmony Hill Cancer Retreat Center

Grief & Loss 3-day Cancer Retreat

You qualify to attend this one-day program at Harmony Hill if:

Questions? Please contact Victrinia Ensor, victrinia@harmonyhill.org, or by phone at 1-360-898-2363 during business hours.

Reservation Request Form

Yes. I would like to attend the "Grief & Loss" cancer retreat on June 11-13, 2010.

Please complete the following reservation request form:

*Signifies required information

*First Name

*Last Name

*E-mail Address

*Mailing Address

*City

*State *Zip

*Home Phone

Work Phone

This program is divided into two groups. Please check the box which applies to your situation:

I have lost my spouse or life partner to cancer.

I have lost a friend, relative, or other loved one to cancer.


*Have you ever attended a cancer program at Harmony Hill? Yes No If yes, list date(s) & program(s) you attended:
*How did you hear about this program?
Your Birthdate	Check One FemaleMale
*When did your most recent loss associated with cancer occur? (Feel free to share as much as you would like.)
*How are you currently feeling physically & emotionally?
List any physical limitations you have that may require that you have assistance in order to participate in the program (such as dizziness or lightheadedness, shortness of breath, difficulty walking on uneven surfaces or stairs)
We serve balanced, primarily vegetarian meals with occasional fish. List any nutritional concerns our staff should be aware of (such as allergies, don't eat fish, dairy, wheat):

In case of emergency, please contact:
*Name
Relationship to you
*Address
*City/State/Zip
*Day Phone
Evening Phone
Cell Phone