Class of 2020 Survivor Sister Retreat Application
Email *
Legal First and Last name: *
Preferred Name: *
Phone: *
Email: *
Include 2 Personal References (unrelated to you): *
What is your ethnic origin: *
Address: *
In the last 3 months, have you suffered from any of the following: *
Current employment status: *
What is your current household income? *
Do you have children? *
How long has it been since you have left the person who abused you? *
Current relationship status: *
Are you currently in an abusive relationship? *
Have you participated in therapy or other therapeutic programs for your healing? *
Did you find it beneficial for you? *
Do you have any physical limitations? *
Do you currently have any pending legal cases or restraining orders against you? *
Have you ever been arrested? Please disclose. *
Our overnight program is March 12-15, 2020. This would require you to sleep at our retreat site without going home each night/day. Are you able to commit to this? *
Are you willing to bring an open mind to the experience? *
Our guests room with 3 other female survivors. Are you comfortable with that? *
By clicking each box I agree to the following terms: *
Please provide a 1-page letter on why you believe you should be selected to attend this retreat. The selection process is based upon this submission. You are encouraged to share your story and tell us why you feel this program is right for you. *
How did you hear about this program? *
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This form was created inside of Break The Silence Against Domestic Violence Inc..