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Adult men (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. All retreats are 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 may be required to purchase a fishing license.

A signed MEDICAL RELEASE from a physician must be received prior to the selected 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: