Abide Retreat Application

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PROGRAM FOUNDATION

I am the vine, you are the branches. He who abides in me and I in him, he brings forth fruit. For without me, you can do nothing! John 15:5

If you abide in Me and My Words abide in you, you will ask what you desire and it shall be done for you. John 15:7

PERSONAL INFORMATION

Legal Last Name *

Legal First Name *

Preferred Name

Email Address *

Phone Number *

Please include your area code

Which Abide Retreat are you interested in attending *

Check all that apply

Military Wives Retreat

Gold Star Mothers Retreat

Minister's Wives Retreat (under development)

Required

ADDRESS INFORMATION

Street Address *

City *

State *

Zip Code *

Date of Birth *

YYYY

Marital Status *

Single

Married

Divorced

Seperated

Widowed

Are you affiliated with any religion? *

(Christian, Buddhist, etc.)

Name of Spouse (if applicable)

Do you have children? *

Yes

What size t-shirt do you wear? *

(Adult Unisex Sizes Only)

Small

Medium

Large

X Large

XX Large

What do you hope to receive from the program? *

EMERGENCY CONTACT INFORMATION

Emergency Contact Name *

Relationship with Emergency Contact *

Spouse

Child

Friend

Other:

Emergency Contact's Phone Number *

MEDICAL INFORMATION

Please bring a list of your medications with you in case of an emergency.

Do you have current medical issues *

PTSD, Depression, Anxiety, etc.

Do you require assistance while you are staying with us? *

(Assistance with dressing, bathing, eating, etc.)

Yes, I DO need assistance during my stay

No, I DO NOT need assistance during my stay

In order to be ambulatory, do you require any of the following? *

Wheelchair

Crutches

Prosthesis

No, I DO NOT require the above to be ambulatory

Are you on a special diet required by your doctor? *

Yes

If a special diet is required, please explain.

Do you have any allergies? *

Yes

If you have any allergies, please explain below. *

Please add N/A if this does not apply

Do you use a CPAP machine? *

Yes

Are you able to participate in recreational activities *

Walking

Hiking/Trails

Horseback Riding

Fishing

I DO NOT want to participate in recreational activities

Required

MILITARY INFORMATION

Are you or your spouse Military or a 1st Responder *

Yes

If yes, please clarify *

REFERRAL INFORMATION

Who referred you to our program? *

Personal invitation from Dave Roever

Family/Friend

Email Announcement

Other:

ELECTRONIC SIGNATURE

By typing your name below, you are stating that all the information you provided is true.

Signature *

Please type your legal name

Submit

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