Central/West Tennessee 2017 retreat application
APRIL 21-23, 2017; PARISH PATCH FARM & INN; NORMANDY, TN
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This retreat is open only to women who live in Tennessee.
Please note that applications from women living outside of TN cannot be accepted.
The deadline to apply to this retreat is February 10, 2017.
Today's date *
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Retreat *
First name *
Last name *
Address *
City *
County (not CountRy) in your state that your city is located in *
please be sure to answer with County, not USA or State.
State *
Zip code *
Daytime phone *
please include area code
Cell phone
please include area code
Email *
Hear about CfR *
Other hear of CfR
PLEASE NOTE: The information gathered below is solely for statistical purposes. It will NOT affect your eligibility in any way.
Ethnicity
Do you have health insurance?
Would you like to receive our e-newsletter?
If you are selected as a participant or as an alternate . . .
  . . You will be sent a registration/waiver of liability form and a medical release form to be completed and returned as soon as possible. (Your oncologist, breast cancer surgeon, or primary care physician must sign the medical release.)
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