2023 March SYR Retreat Application Part 1 Are you a registered Living Beauty? * Yes No I understand that at this retreat, there will be a mixture of women who have and have not had the covid vaccine. * Yes I have attended a Serenity Yoga Retreat with Tari Prinster in the past * Yes No If so, what year did you attend First Name * Last Name * Email * Street Address * 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) Phone * 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% 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 Date of your most recent diagnosis? * 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 Do you have physical issues that limit your movement? * NoYes If yes, what limitation? 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? * We have learned that our retreats are unique and powerful because of the connections and bonds women build with each other. We feel it is important for each woman to attend each workshop and stay on the retreat grounds in order to fully experience the community that is formed during the retreat. How comfortable do you feel in groups where you may not know everyone? If you are not comfortable, would you be able to challenge yourself to be present during the workshops? * At this retreat, women will be in different stages of recovery and remission. Is this something you would be comfortable with and be able to be present in? * How would you describe your current support system? * In your personal life, how do you handle feelings of sadness, depression and loneliness? * 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. * Thank you for filling out this application. Acceptance and waitlist emails with be sent out on February 8, 2023. Please direct any questions to [email protected]. Be sure to click SUBMIT below.