Harmony Hill Cancer Alum Retreat Registration Form


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Registration for "Thriving Beyond Cancer" series

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

You are a cancer survivor or a cancer caregiver
You are physically able to move between buildings and short distances

While anyone who meets the above criteria is welcomed to register, we do strongly recommend participation in one of our core programs (Tools for the Journey, or a 3-day Cancer Retreat) prior to participating in our Thriving Beyond Cancer retreats.

To register:
Please submit the online form below to reserve your space.

Questions?
Contact Victrinia Ridgeway, Program Coordinator, , victrinia@harmonyhill.org or by phone at 1-360-898-2363 during business hours.

Yes! I want to attend a "Thriving beyond Cancer" program

NOTE: Registration for caregivers uses a different form.
Click for Caregivers registration for a caregiver workshop

*Signifies required information

Harmony Hill Privacy Policy

*First Name

*Last Name

*E-mail Address

*Mailing Address

*City

*State *Zip

*Home Phone

Work Phone

Do you wish to have a spouse/companion attend with you? A spouse/companion may attend with you only for retreat dates specified as open to spouses/companions. All other retreats are restricted to those with a cancer diagnosis.

NoYes If yes, list their name:

Program(s) you wish to attend:

		Monday, March 8, 2010 - Caring for the Caregiver
		Monday, May 17, 2010 - Cancer and Your Emotions
		Monday, July 26, 2010 - Expressive Arts: Play as a Healing Tool
		Monday, Sept. 27, 2010 - After the Storm: Moving from Surviving to Meaning
		Monday, Nov. 22, 2010 - Journaling for Women: A Resource for Inner Peace and Healing


*How did you hear about this program?
*Have you ever attended a cancer program at Harmony Hill? Yes No If yes, list date(s) & program(s) you attended:
Your Birthdate (mm/dd/yyyy)
Please Check One Female Male
*What is your cancer diagnosis? (please be specific)
*Approximate date of your initial diagnosis
Dates of recurrence, if any
Do you have any metastasis? Any fractures and/or seizures due to metastasis? If yes, please describe specifics:
*How are you currently feeling physically?

Doctor's Info:
*Name of your primary medical doctor
*Doctor's address
*City/State
*Doctor's phone

Physical Limitations 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)
Food Restrictions 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