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Retreat Registration

Retreat Registration

RETREAT REGISTRATION
FILL OUT THE FORM

Please fill out the form below to register for one of our retreats. If you have any questions, please contact us.

Revive Retreat Registration Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County(Required)

Age(Required)

Preferred Language(Required)

Gender(Required)

Female

Male

Transgender

Non-binary / non-confirming

Prefer Not to Answer

Our programs are funded by many donors from the community. We must report aggregate data (ex. demographic and geographic) of our participants. The demographic information you provide assists us in attracting more support to continue our programs to serve diverse populations. The information gets totaled and never includes individual’s names or contact information.

Race / Ethnicity(Required)

African American / Black

Asian

White

Hispanic/Latino

American Indian/Alaskan Native

Native Hawaiian/Pacific-Islander

Other

Prefer Not to Answer

If Other, what is Your Race / Ethnicity?(Required)

Retreat You'd Like to Attend(Required)

June 22: Latina Support Group Retreat (Spanish Only, 10am-4pm)

Sept. 27-29: Couples Retreat | Menucha

Have you attended a Pink Lemonade Project retreat in the past?(Required)

Yes

No

When?(Required)

Are you out of active treatment? If so, how long has it been?(Required)

To attend a Pink Lemonade Project retreat, a participant must be at least one year out of active treatment (surgery, chemotherapy, radiation).

Emergency Contact Name(Required)

Emergency Contact Phone Number(Required)

Proof of Covid Vaccination File Upload(Required)

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

For the health and safety of all attending, please provide a copy or photo of your vaccination. Click the field to select a file or drag and drop your file on the field.

Check boxes to confirm you:

Would like to sign up for general email blasts which include PLP’s monthly program information.

Would like to sign up for email blasts for metastatic breast cancer patients which include quarterly newsletters and information on MBC related events.

Pink Lemonade Project
1207 Washington Street, Suite 125,
Vancouver, WA 98660 | Map

Phone: (360) 952-3814

Pink Lemonade Project is a 501(c)3 nonprofit
Tax ID #37-1699288

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