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Adult male veterans (age 21+) in any stage of treatment, recovery or in full remission from all forms of cancer are eligible to attend one Reel Recovery Retreat. The Retreats are completely free to the participants; Reel Recovery provides all meals, lodging and fishing equipment. Participants are responsible for their own transportation to the Retreat location, and should contact PHWFF for assistance with transportation costs as needed.

A signed MEDICAL RELEASE from a physician must be received prior to the retreat.

Also available as a printed form.

*required

Desired Retreat*

Your Name*

Address*

City,*

State*

Zip*

Cell Phone

Home Phone*

Your Email

Name of Emergency Contact During Retreat*

Emergency Contact's Phone*

Your Age*

Shoe Size (for boots)*

Wader Size (Sm, Med, Lg, XL, XXL)*

Occupation

How did you hear about Reel Recovery? (referring clinic/hospital, person, etc.)*

Where do/did you receive your cancer treatments?*

Please describe your experience with cancer (type of cancer, date of diagnosis, treatment, current status).*

Do you have any physical restrictions and/or special needs?*

Do you have any dietary preferences or requirements?*

Please describe any additional medical conditions (heart disease/stroke, high blood pressure, diabetes, seizures, orthopedic, etc.)

Please describe all allergies (to medications, bees/insects, food, etc.)

Have you ever attended a support group or retreat before?*
yesno

If so, please describe:

Please feel free to provide any additional information: