2024 May Elemental Healing Retreat First Name * Last Name * Email * Phone * Address 1 * City * State/Province * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoU.S. Minor Outlying IslandsVirgin IslandsArmed Forces AmericasArmed Forces Europe, the Middle East, anArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavut TerritoryOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory Zip * Birth Date * // (mm/dd/yyyy) Approximate Annual Household Income * $25K or less$25-40K$40-60K$60-80K$80-100K$100K + How many people are in your household? * 123456789 Has your cancer impacted your household income? * No. Income has not been impacted.Yes. Income dropped 25%Yes. Income dropped 26-50%Yes. Income dropped 51-75%Yes. Income dropped 76-100% Has your cancer experience impacted your household expenses? * No. Expenses have not been impacted.Yes. Expenses increased 10-25%Yes. Expenses increased 26-50%Yes. Expenses increased 51-75%Yes. Expenses increased 76-100% How would you self-identify your ethnicity? (This question is solely for our own demographic program purposes) * Asian/ Pacific Islander Black Latina Native American White Mixed Ethnicity Other I decline to answer Type of Cancer(s) * Year Diagnosed with Cancer * Year of your original diagnosis? (if different from your most recent diagnosis) 200520062007200820092010201120122013201420152016201720182019before 2005 Where are you on your cancer journey? * I am done with treatment, and am now transitioning into my “new normal”I am in treatment using a combination of conventional and holistic therapiesI am in treatment using conventional therapiesI am in treatment using holistic therapiesI am NED (No Evidence of Disease) for less than 1 yearI am NED and on maintenance treatmentI am NED for 1-5 yearsI am NED for more than 5 yearsI am NOT NED and have chosen to use holistic healing treatment optionsI am NOT NED but have chosen not to seek any form of treatmentI have been diagnosed, and haven’t started treatment yetI have been re-diagnosed and am choosing to use a combination of conventional and holistic therapiesI have been re-diagnosed and am choosing to use only conventional therapiesI have been re-diagnosed and am choosing to use only holistic therapiesMy battle will last a lifetime, I will always be in treatment Please list the programs/organizations that provide you support regarding your cancer diagnosis as well as the type of support they provide As of today, what are your greatest physical and emotional needs? * How do you hope to benefit from this retreat? * How does working with the elements speak to you? * Do you have any experience working with the elements, intention setting and/or visualization? * Have you ever worked with complementary healing modalities like Reiki and hypnotherapy? * Release of Liability – I voluntarily participate with full knowledge that there is risk of personal injury (including death), property damage and/or other loss. On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify and hold harmless The Foundation for Living Beauty, its subsidiaries and affiliates, and their respective officers, directors, employees, volunteers and agents from and against any and all losses, liabilities, damages, actions, suites, demand or claims, of any nature or cause (each, a Claim), including costs and attorney’s fees incurred by The Foundation for Living Beauty in connection with such Claim, arising from damages or injuries which may be sustained or caused by me, directly or indirectly, in connection with my participation with The Foundation for Living Beauty, whether or not caused by The Foundation for Living Beauty or it’s officers, directors, employees, or agents or otherwise. By typing my name in this form, I agree that The Foundation for Living Beauty is in no way responsible for the safekeeping of any personal belongings while I attend Living Beauty events. My full legal name here acts as my signature and acknowledgement of liability. *
