Lung Cancer Wellness Retreat Application
Wind River brings together cancer survivors who want to further explore living more fully and authentically - mind, body & spirit. Join us for an in-person Wind River Lung Cancer Wellness Retreat in partnership with the Lung Cancer Initiative (LCI) .  

September 22nd , 23rd,  & 24th, 2023
Raleigh, NC
Friday 10:30am through Sunday 4pm. (participation across all three days is required; lodging is provided)
NO charge thanks to the Lung Cancer Initiative!

Experience the healing essence of Drumming by the Lake, Energization Yoga (no experience necessary!), Nature Walks in the Botanical Garden, Plant-Based Nutrition, Healing Touch, plus lots of outside time, being playful and connecting with others!  This year, we gather in the serene garden setting of Camp La TeDa that also offers wooded grounds complete with a beautiful sunset lake. Hosted by team, Teri Barron and David Wheeler, (lung cancer survivor, mentor and Wind River alum) and David (lung cancer mentor, caregiver expert, and Wind River retreat alum). A dynamic duo.

Each application will be followed up with an email, and phone call, but in the meanwhile, here are a few key details:  

- Open to both male and female lung cancer survivors residing in North Carolina.
- Participants must be able to climb stairs, walk on uneven wooded landscape and handle their own daily medical needs.
- Location -  Raleigh/Garner NC.
- Hotel lodging is included for Friday and Saturday 
- One additional night of lodging (Thursday night) is available for those survivors who live outside of the Raleigh area and would like to avoid driving on the morning of the retreat. (optional)
- Transportation is the participant’s responsibility.  We do try to connect fellow participants who wish to carpool, where it is an option.  
- All Retreat meals are included and are whole-foods plant-based (vegetarian)
- No smoking or alcohol consumption during the Retreat.
- There will not be any wood burning bonfires.
- COVID-19 protocol has been carefully laid out and will be followed for the upmost safety of all participants. More details to follow closer to the Retreat, but at a minimum all participants will be required to take rapid COVID tests as provided.

*We are open to male or female lung cancer survivors regardless of ethnicities, faith traditions and sexual orientations. Again, this retreat is open to North Carolina residents .... and while we may not be able to accommodate and accept everyone, we do connect personally with everyone who applies!  

*Be sure to click the "SUBMIT" button at the bottom. (Required fields are marked with a red asterisk.) Allow 15 minutes to complete.

Your host, Cheryl Lecroy, Teri Barron and the Wind River Team

Sign in to Google to save your progress. Learn more
Last Name *
First Name *
Home Phone #
Cell Phone # *
E-mail Address *
Street Address *
City *
State *
Zip *
Personal Information
Gender *
Height *
Enter your height.
Weight *
Enter your weight.
Age *
Enter your current age.
Date of Birth *
How did you hear about us? *
Tell us who referred you or how you found out about us.
Relationship Status?  If you have children - what ages?
Let us know your relationship status (married, single, committed relationship, ...) and if you have children.
Are you on Facebook?   *
* If "Yes", be sure to search Facebook for "Wind River Cancer Wellness Retreats" and click "Like"!
Required
If you have a sharing site like "Caringbridge", include here (optional)
Emergency Contact Information
Contact Name & Relationship *
Enter the name of who we should contact in an Emergency AND their relationship to you (spouse, friend, etc.)
Contact E-mail Address(s). *
Enter your emergency contacts' E-mail address(s).
Contact Phone #s. *
Enter your emergency contacts home and/or cell #.
Oncologist / Primary Care Physician's Name: *
Enter your Oncologist or Primary Care Physician's Name.
Physician's Office Phone. *
Enter your Physician's Office Phone.
About YOU
This section will help us get to know you a little better so that we can determine how we can best serve you.
1.   Spirit / Morale *
Tell us a little about your current spirit or morale.
2.        What do you hope to gain? *
Tell us what you hope to gain from your Wind River Retreat experience.
3.  Exercise *
Tell us if you are currently doing any exercise, and if yes, tell us What and how often.  
4.  Support *
Tell us who or what are the major sources of support in your life (family, friends, religion or spiritual practice, exercise, etc)?
5. Complimentary or Integrative Therapies *
Tell us about any complementary therapies you are currently involved in (Yoga, Tai Chi, Support Groups, Healing Touch, Music, Art, PT, Acupuncture, etc.) or type "NONE".
6. Currently Working? *
Tell us if you are currently working? And if so, the nature of your work
7. Retreat Experience *
Tell us about any previous retreat experiences or other retreats you plan to attend this year (program name and approximate date).  If none, type "NONE"
Physical Limitations
Each participant must be able to walk the equivalent of several flights of stairs and on sloped gravel/wooded paths.
1.  Specific Physical Limitations *
Tell us about any physical limitations that may make it difficult for you to participate in the retreat activities (wheelchair, walker, fatigue, unable to climb stairs or get up off the floor, use of oxygen tank, etc.) or type "NONE".  We will talk with you more directly if any of these things are of concern to you.
2.  Neuropathy *
Tell us if you are you experiencing neuropathy.   If "yes", please describe.  If not type "NONE".
3.  Bones/Joints / Major Surgeries *
Tell us if you have had any bones / joints removed or replaced, or any major surgeries.  If so, please describe.  If not type "NONE".
4.  Medical Needs * *
I can handle my own daily medical needs & will bring needed supplies.
5a.  Allergies - part I *
Tell us about any NON-FOOD allergies you have (drug, animal, bee,) and how severe.  If note type "NONE".  
5b.  Allergies - part II *
Tell us about any FOOD allergies you have (peanuts, dairy, etc) and how severe.  If none type "NONE".
6.  Smoking *
This is a smoke free event.  Does this present a concern for you? (we can talk further)
7.  Other Health Conditions *
Tell us about any other health conditions or issues we should  be aware of (diabetes, digestive, heart or lung conditions,  sleep apnea, COPD, auto-immune deficiencies, etc.).   If not type "NONE"
 Just a few more details ...
1.  Type of Cancer *
What type of lung cancer did or do you have?
2.  Stage *
Tell us the current Stage of your cancer (I-IV, metastatic, local, re-occurrence) and the approximate date you were first diagnosed. (and re-diagnosed)
3. Currently in Treatment? *
Tell us if you are currently in treatment and if so, how long and what kind?  Or, if you have up coming treatments or surgeries and when.   (this is generally not a problem, we just need to know)
3A. Completed Treatments?
 If you have COMPLETED treatments briefly highlight what you underwent and when your treatments finished.
4.  Dietary Preferences *
Our healthy vegetarian menus are carefully planned.  We do not serve meat, but may cook with dairy products and eggs.  Please share any dietary preferences you have so we can discuss if we are able to adequately accommodate them.  If no preferences type "NONE"
5.  COVID Protocols *
COVID protocols will be followed by all participants based on the risk levels at the time of the retreat as established by Wind River in conjunction with Lung Cancer Initiative.   All participants are required to take a rapid COVID test upon arrival at the retreat (to be provided) and more may be required later in the weekend. Also proper masks / face coverings may be required for all participants. Final decisions on masks/face coverings will be shared with participants closer to the Retreat. Your safety and that of all the participants is of the upmost
Transportation
Transportation is the participant’s responsibility.  We do try to connect fellow participants who wish to carpool, where it is an option.  

Next Steps
You should expect a phone call from us within 2 weeks of submission of your application.  If you have NOT heard from us in that time period please email us at info@WindRiverServices.org.

Unfortunately we are not able to accept everyone due to space limitations, as well as our goal to create a diverse group for sharing purposes.  

For those who are accepted, we will provide you with an Informed Consent Statement and a Tai Chi, Yoga, Healing Touch & General Liability Release form for signature, as well as directions, weather expectations, and information on what to bring.

We do not charge participants, to allow our participants to focus on healing, rather than economic concerns. These Retreats are made possible through charitable donations by caring individuals to Wind River Services, a 501(c)3 nonprofit organization. This retreat is also generously supported by The Lung Cancer Initiative.
Application Signature
In making this application to Wind River Cancer Wellness Retreats and Wind River Services (our 501(c)3 nonprofit nondenominational center), I state that this information is complete and accurate.  
Sign Here *
Type your name here as proof that all information given is complete and accurate.
Signature Date *
Submit
Ensure that all required fields (marked with a red asterisk) have been properly filled out.  

When complete and signed simply click the "SUBMIT" button below.

If you have problems submitting this form please contact us at:   (884) 723-2442  or Cheryl@WindRiverServices.org

Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Wind River Services. Report Abuse
Google Forms