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Registration for "Tools for the Journey: Living with Cancer"
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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
- You have not attended a cancer retreat held at Harmony Hill in the past 12 months
To register:
Submit the online form below to reserve your space,
OR print out the printable form (PDF) and mail your registration
Questions? Contact either Cindy Shank, cindy@harmonyhill.org or Anna Cartwright, anna@harmonyhill.org, or by phone at 1-360-898-2363 during business hours.
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Yes! I want to attend "Tools for the Journey: Living with Cancer" |
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* = required Harmony Hill Privacy Policy |
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*First name |
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*Last name |
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*E-mail address |
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*Postal address |
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*City |
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*State |
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*Zip |
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*Home phone |
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Work phone |
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Date you wish to attend:
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Monday, February 4, 2008 |
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Wednesday, April 2, 2008 |
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Monday, June 16, 2008 |
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Monday, August 25, 2008 |
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Monday, October 20, 2008 |
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Monday, December 1, 2008 |
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Birthdate
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FemaleMale
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*Have you already applied to attend a Harmony Hill
weekend cancer retreat? Yes No
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Do you wish to have a caregiver or loved one attend with you? |
If "yes," list their full name & relationship:
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*How did you hear about this program? |
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*What is your cancer diagnosis?
(please be specific) |
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*Approximate date of your initial diagnosis |
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Dates of recurrence, if any |
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Do you have any metastasis? Any fractures and/or seizures due to metastasis? |
If yes, please describe specifics:
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*How are you currently feeling physically? |
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*Name of your primary medical doctor |
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*Doctor's address |
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*City & state |
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*Doctor's phone
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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) |
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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):
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In case of emergency, please contact: |
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*Name
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Relationship to you
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*Address
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*city-state
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*Phone:
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dayevening
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cell
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| 1/16/08
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CANCER RETREATS  FACILITY RENTALS INDIVIDUAL RETREATS RETREAT CALENDAR
HEALTH PROFESSIONALS INFO CONTACT US HILL STORE PRIVACY POLICY
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