Knight's Cabin Retreat Application
Doctor's House Inn
Old Hopeall Rd, Green's Harbour, NL
May 4-6, 2018
Email address *
Personal Information
Full name: *
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Age: *
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Gender: *
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Street address: *
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City: *
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Province: *
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Postal code: *
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Home phone number: *
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Cell phone number:
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E-mail address:
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May we add you to our e-newsletter mailing list?
For rooming purposes, is someone else you know also applying to attend this retreat as a survivor? *
If yes, what is their name?
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Supporter Information
Do you intend to have a supporter accompany you during the retreat? *
If so, what is their full name?
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What is their relationship to you?
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Does your supporter have any dietary restrictions? If so, what are they?
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Does your supporter have any physical restrictions that may limit their physical activity? If so, what are they?
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Does your supporter have any other medical conditions or issues that we should be aware of? If so, what are they?
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For rooming purposes, are you comfortable sharing the same bed as your supporter?
Medical Information
Type of cancer: *
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Name of physician: *
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Physician phone number: *
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Emergency contact person: *
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Emergency contact person phone number: *
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During an average week, how much physical activity do you engage in? *
Do you have any physical restrictions that may limit your physical activity? If so, what are they? *
Your answer
Do you have any other medical conditions or issues that we should be aware of? If so, what are they? *
Your answer
Do you have any dietary restrictions or allergies? If so, what are they? *
Your answer
Additional Information
In a few sentences, please summarize your cancer journey thus far. Please include when you were diagnosed and your current treatment status (recently diagnosed, in treatment, finished treatment, hormone therapy, etc...). *
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Please share with us why you would like to attend this retreat and why you believe you would benefit from it. *
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Please share with us what you hope to gain and take away from this retreat. *
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Do you have any questions for us? Please feel free to ask them here:
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A copy of your responses will be emailed to the address you provided.
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