Retreat Form

Name

First Name Last Name

The name you like to be called

Email

example@example.com

Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Referred by / How did you hear about the LLN Retreat:

Ethnicity

Current employment status

Number of Children

Current relationship status:

Have you participated in D.V. Counseling or received any treatment related to healing from trauma?

Yes No

If so, was it helpful?

Yes NO

In the last 3 months, have you suffered from any of the following:

Suicide Depression Anxiety Post Traumatic Stress Disorder Bi-Polar Disorder None of the above

Do you have any physical limitations?

Yes No

Are you willing to bring an open mind to the day’s experience and embrace your new survivor sisters?

Yes No

This a full one-day retreat starting from 8am to 6p (time subject to change) with a central pick up and drop off location in Brockton, MA. Are you able to dedicate the day to the event, bring an open mind and be at pickup location on day of retreat?

Yes No

List 2 Personal References (not related to you):

Click to agree to the following:

I will be welcoming, accepting, compassionate, and comforting to my fellow survivor sisters.

Upon acceptance, I understand I must submit a non-refundable $30 registration fee.

I understand no drugs or alcohol are allowed the day of retreat.

I understand I must provide my own transportation to and from the Brockton pick-up location.

I understand that I must be on-time for pick-up at the Brockton pick-up location and if more than 15 minutes late, you will be left behind.

I understand children are not allowed at the retreat.

I understand my photo may appear in post retreat media and I am ok being listed as an abuse survivor.

Please provide 1-2 paragraphs letter on why participating in this retreat is important to you. The selection process is based upon this submission.

Do you agree to the above?

I Agree I Do Not Agree

My Products

LLN Retreat Ticket $ 30.00

Quantity

Total $ 0.00