2025 Overnight Retreat Application
You're invited to join us for our Overnight Retreat at The Pillar and Post Inn and Spa in Niagara-on-the-Lake this upcoming February! 

Through meaningful peer-led conversations, light movement, heartfelt connections, and expert discussions our retreats are designed for you to feel supported while facing/have faced a cancer diagnosis. Our retreats are free to attend for self-identifying young women facing any type of cancer between the ages of 18-40.

Pillar and Post Inn and Spa
Friday, February 21 to Saturday, February 22, 2025
48 John St W, Niagara-on-the-Lake, ON L0S 1J0

Please submit your application by December 9th, 2024. If you're application is received after the deadline, you will be placed on our waitlist. Our team will connect with you once your application has been received.

Please note, there are limited spaces at our retreats, and measures will be put in place to ensure you feel safe/comfortable during your time with us.
Sign in to Google to save your progress. Learn more
Name (First + Last) *
Email Address *
Mailing Address (Street, City, Province, Postal Code) *
Birthdate *
Please note: Our programs are intended for young women who identify as female, between the ages of 18-40 facing any type of cancer across Canada. If you are under 18 or over 40 you are unable to attend our retreats.
Phone Number *
What are your prefered pronouns? *
Emergency Contact Name + Phone Number *
Please provide us with the name and phone number of your emergency contact
Do you have any dietary restrictionns/food alleriges or other allergies we should be aware of?
 *
If yes, please specify the allergen and indicate treatment required. For allergies like peanuts and seafood, be specific as possible answering: can the food be cooked and served in the same room as you. 
All participants with a known anaphylactic allergy are expected to bring an EpiPen to the retreat.
If none, please state N/A.                                                                                                        
Do you have any special needs/requirements?
 *
Example: anxiety, depression, panic attacks, mobility, visual impairment, limited use of fine motor skills or other details that are important for us know to ensure programming is inclusive.
If none, please state N/A. 
Type of cancer *
How long have you been in treatment for/how long have you been post-treatment? *
Please note, you must have been diagnosed with cancer between the ages of 18-40, and can be in active treatment or post-treatment within 5 years of your diagnosis.
What hospital(s) did you receive treatment at?
 *
How many retreats have you attended?
 *
Please note, if you've attended 5 Retreats you will automatically be placed on the waitlist, as it is within our mandate that you can only attend 5, unless a spot becomes avaiable.
We know what it's like to hear the words 'You have cancer'. Tell us about yourself, outside of your cancer world. What do you love to do?
 *
Minimum 250 characters
Roommate/Occupancy Agreement
 *
We find the best moments are when you create connections with other women facing cancer. Our Retreats operate on a double occupancy room. By selecting "YES", you agree to the above policy of ours to create meaningful connections while attending our retreats.

If you have a health concern sharing a room, we're happy to look into single accommodations depending on availabilty, please note there will be a room charge for this. Get in touch with Melaina at programs@pinkpearlcanada.org as fundraising is an option. 
Please let us know if you have a preference with who you share a room with
 *
For example, let us know if you prefer someone who is the same age as you are, has the same type of cancer, based in the same geographical area, is a friend, etc. 
If you would like to share a room with a friend, please write your name/your friends name in the space below.

We'll do our best to accomodate your request.
If you do not have any prefences on roommate selection, please type N/A.
Connect with your roommate before the Retreat
 *
By selecting 'Yes', I give Pink Pearl permission to share my e-mail with my roommate to connect before the Retreat.
We'll be creating a WhatsApp group for Retreat attendees to connect beforehand! If you select "YES", you consent to us adding you to the group. *
This is a great way to connect with your peers, stay in the know with Retreat updates (we'll also send via email), this is a great way to carpool, or if you have any questions that you think the whole group would want to know!
If you would like to join the WhatsApp group, please share your phone number associated with your account below. If not, write N/A. *
Waitlist
 *
If a spot opens up on our waitlist within 24 hours of the retreat, would you like to be notified to attend last-minute?
Do you have a yoga mat?
 *
If yes, please bring with you to our Retreat. We will have a few extra mats to use.
Agreement of Release Consent Form
 *
I consent that I have read and understood all of the below information.

Attendance: You are expected to attend the Retreat in its entirety. You know your body best, so feel free to move around, or stand up while the retreat is happening, we want to make sure you are most comfortable during the retreat. 

If something comes up before the Retreat begins and you are no longer able to attend, please contact us at programs@pinkpearlcanada.org, or reach out to Melaina at 289-687-5711. 

Age: Our Retreats are open to self-identifying women facing any type of cancer or anyone with cancer of gynecological origin, between the ages 18-40 who have been diagnosed between these ages.

Retreat Costs: Our Retreats are free to attend. All meals, based on double occupancy - conference fees/overnight accommodations, and non-alcoholic beverages that we provide are included during your time with us. 
Additional costs incurred by participants will be the responsibility of the participant (ex. Room service, in-room movies, damages to room, beverages consumed at meals besides the ones we provide, luggage drop-off, parking, travel expenses, activities attendees participate in outside of our Retreat - ie spa, etc) 
Please note, upon checking in, you will be asked to provide a credit card for incidentials. 

Guests: Our Retreats are a time for you to get away from normal life, and are intended for those who have confirmed registration. If for some reason you need to have a caregiver attend for medical reasons, they are unable to be apart of our programs and must cover their own costs during the duration of their stay. This will not be arranged by Pink Pearl, and you must state on your application that this is the case.

Transportation: You must arrange your own method of transportation, and cover parking costs if you are driving to the retreat. If you'd like to see if you can carpool with someone, ask us to be added to the Private Facebook Group to connect with others attending our retreat. 

Medical Emergency: Please note, we will have a nurse and/or social worker on-site at the retreat. They are strictly here in case of an emergency, and will not administer any medication, or advice for your particular cancer journey. In case of a medical emergency, we will call an ambulance and will contact your emergency contact to advise of the emergency.

Support: Our social worker, will be present and here to support you at our retreats. If at any point you need to chat with them, please know they are here for you.

External Speakers: As part of the retreat, external speakers are invited to facilitate sessions. Pink Pearl will not provide external speakers with contact details of participants. The speaker may ask participants to voluntarily provide contact details, and that is up to your discretion.

Confidentiality: Everything discussed will remain confidential on the part of Pink Pearl and we ask the same of participants. The Retreat Coordinator will ensure that personal information of participants is only used in the context of programming activities and is not given out to other volunteers, etc.

Concerns: Any concerns/complaints prior to, during or after the retreat should be communicated to the Programs Team and will be attempted to be resolved in a time sensitive manner. If the issue is not resolved, then it should be brought to the attention of the executive team.

Check-in and Check-out: We will provide you with time to check-in/out of the hotel. Luggage may be kept at the front desk upon check-out.

Feedback: Prior to the Retreat and at its conclusion, participants will be asked to complete a confidential evaluation form that will be reviewed internally.  
COVID-19 Liability Waiver *
We are aligning with local COVID-19 regulations and closely following what is required of them. Masks are optional to ensure the space feels safe for all. Please note retreat leaders will not be wearing masks, and as we will be in public facilities that don’t mandate masks, if you are attending the retreat you should be comfortable with this possibility. 

By attending this program, I hereby agree to the following:
  1. I acknowledge the contagious nature of COVID-19 and that some public health authorities still recommend practicing social distancing. 
  2. I acknowledge that the Pink Pearl Foundation has put in place preventative measures to reduce the spread of COVID-19.
  3. I further acknowledge that Pink Pearl Foundation can not guarantee that I will not become infected with COVID-19. I understand the risk of becoming exposed to and/or infected by the COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, the Pink Pearl Team, supporters, program attendees and their families.
Photography Consent *
I acknowledge that as a participant in the Pink Peal's Retreat I may be photographed or I may share photos of my experience virtually that will be re-shared by Pink Pearl. I hereby consent to the use of my image and likeness by the Pink Pearl on its website at http://www.pinkpearlcanada.org, on social media and as part of its marketing materials. I understand that if I no longer wish to have the Pink Pearl use my images and likeness that I should contact the Pink Pearl at programs@pinkpearlcanada.org.
Communication Consent *
I consent to the receipt of email communications, including but not limited to, announcements, event and program invitations and newsletters, from Pink Pearl using my given email address.
Liability Waiver & Consent Form
 *
I, the undersigned, hereby agree to the following: 
1. That I am participating in the Pink Pearl Retreat and I recognize that some of the activities, including but not limited to yoga, a walk, etc, that I will participate in may require physical exertion. I am aware of the risk and hazard involved. I acknowledge that I will seek medical advice if I know or subject that my physical condition may be incompatible with the Pink Pearl Retreat activities.
2. I accept full responsibility for any risks, injuries or damages known or unknown which might occur as a result of participating in the Pink Pearl Retreat. I also accept responsibility for any personal or property damage caused as a result of my participation in the Pink Pearl Retreat. 
3. I knowingly and voluntarily waive any and all claims I may now and in the future have against the Pink Pearl Foundation, all of the organizers of the Pink Pearl Retreat, and the Retreat Venues, Vintage Inns, and their organziers (together, the “Parties”) for injury and damage that I may sustain as a result of my participation in the Pink Pearl Retreat.
4. Furthermore, I agree to release the Parties from any and all liability for any loss, damage, expense or injury that I may suffer, either directly or indirectly, from either my use of Zoom or my presence at the Pink Pearl Retreat due to any cause whatsoever. 
5. Confidentiality: The information you are sharing with us for our Retreat is very private in nature and we respect that. It is for this reason that everything shared on your application and throughout the Retreat is strictly confidential. We would also ask that you don’t discuss it outside of the Retreat. You are however, certainly welcome to share what you said privately at home.
Please type your name here to confirm you have read and understand the Agreement of Release, Liability Waiver & Consent Forms above. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pink Pearl Foundation.

Does this form look suspicious? Report

Google Forms