Retreat Application

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. The Retreats are completely free to the participants; Reel Recovery provides all meals, lodging and fishing equipment. Participants are only responsible for their own transportation to and from the Retreat location.

A signed MEDICAL RELEASE from a physician is required prior to the Retreat.

Also available as a printed form.

Retreat Application

First name

Last name

Address

City

State

Zip code

Cell phone

Home phone

Emergency contact name

Emergency contact phone

Age

Shoe size (for boots)

Occupation

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

Type of cancer; Date of diagnosis; Current status.

Where do/did you receive your cancer treatments?

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

Do you have any dietary preferences or requirements?

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

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

Have you ever attended a support group or retreat before?

Yes

If yes, please describe:

Please feel free to provide any additional information:

Thank you for your Application! We will contact you shortly.

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Retreat Application

Retreat Application

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