Particpant Registration - Online

Name *

First Name

Last Name

Phone *

Please enter the phone number you'd like us to use when we call.

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How Did You Hear About Our Retreats?

Please select all that apply

Past Participant/Volunteer

Support Group

Healthcare Worker / Doctor

Web Search

Other

Do you have any prior fishing or fly fishing experience? *

Seeing "A River Runs Through It" does not count. However, it does earn you a special prize!

Yes

No

First Retreat Choice *

August 4th-6th

August 11th-13th

August 18th-20th

August 25th-27th

Second Choice *

August 4th-6th

August 11th-13th

August 18th-20th

August 25th-27th

None

I am a woman over 18 years of age who has received a cancer diagnosis. *

Yes

No

COVID-19 Vaccination *

All Participants are encouraged to be vaccinated.

Yes, I will be fully vaccinated and have received one booster by my retreat date.

No, I will not be fully vaccinated.

Do you Have Any Allergies or Sensitivities? *

We like to make a safe and comfortable environment for everyone. Options selected below will be discussed with the retreat coordinator.

Food

Medication

Environmental

Chemical

Insects

Carry Epi-Pen

None

Any Current Health Issues, Physical Restrictions or Special Needs? *

These will be reviewed with the retreat coordinator.

COPD/Asthma

Diabetes

High Blood Pressure

Afib/Stroke

Orthopedic/Neuropathy

Seizures

Physical Limitation(s)/Restriction(s)

Healing Surgical Wound or Open Port Line

Other

None

Do You Think You Can... *

- Sit and/or stand for at least an hour on level and uneven ground, on land and in a stream. Note: we provide some assistance in the stream. - Go up and down 20 stairs at least 4 times a day. - Lift and cast a fly rod for 1-2 hours or more. -Verbally communicate needs. -Walk or stand without use of a cane, walker, wheelchair or related device. -Have little to no bodily pain due to walking, wading, standing, or sitting for an extended period of time.

Yes

Maybe

No

Emergency Contact Phone *

(###)

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Car Pooling

We make every effort to make sure all who want to come can. If you need some help or can help someone, please let us know.

Not Interested / Needed

I Could Drive Someone

I'd Ride With Someone

I Can Drive or Ride

I Understand This Is Just the First Step *

Remember, submitting this information does NOT represent an official registration. This is the First Step.

Yes. I understand this is the First Step!

First *

I have completed the above information and acknowledge it true. I acknowledge that I am a voluntary participant and I agree to assume responsibility for myself. I understand misrepresentation or omission of facts requested is cause for dismissal of my request as a Reeling & Healing participant. If appointed as a participant, I agree to adhere to the general policies and guidelines set forth by Reeling & Healing Midwest and to fulfill my participant responsibilities to the best of my ability.

I Acknowledge

Second *

I acknowledge that the Reeling & Healing Midwest volunteers are not providing medical or psychological diagnosis, treatment, opinions, referrals, guidance, assistance, or counseling for me specifically and that these volunteers are present for the purpose of facilitating involvement and not to provide professional services to group participants. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and that my emergency contact will be notified as soon as possible in case of an emergency. In the event they cannot be reached, I hereby authorize Reeling & Healing Midwest to acquire medical treatment for me.

I Acknowledge

Third *

I further agree to waive any claims against Reeling & Healing Midwest, its officers, employees, agents or volunteers resulting from any and all losses, damages, costs and expenses that are caused by or arise out of any act, omission, default, negligence or other misconduct by Reeling & Healing Midwest in connection with this participation.

I Acknowledge