Cancer Retreats - for those facing cancer


About	Facilities	Calendar	Programs	Ways to Give	Contact Info

Registration for "Tools for the Journey: Living with Cancer"

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

You have received a cancer diagnosis at some time in your life, and can provide your physician's name and contact information

You are physically able to move between buildings and short distances

To register:
You may either submit the online form below to reserve your space, OR print out the printable form (.pdf) and mail your registration.

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

Yes! I want to attend "Tools for the Journey: Living with Cancer"
*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:
Date you wish to attend:
	Monday, Feb. 22, 2010
	Monday, April 26, 2010
	Monday, June 28, 2010
	Monday, August 23, 2010
	Monday, Oct. 11, 2010
	Monday, Dec. 6, 2010 - For Men with Prostate Cancer: no companions

*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
General Medical Info:
*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
*Phone (Day)
*Phone (Evening)
*Phone (Cell)