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 *

Zip *

Birth Date *

// (mm/dd/yyyy)

Phone *

Approximate Annual Household Income *

How many people are in your household? *

Has your cancer impacted your household income? *

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)

Date of your most recent diagnosis? *

Where are you on your cancer journey? *

Do you have physical issues that limit your movement? *

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.