Cancer Lifeline CARES

Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Phone *
Please provide your personal pronouns:	He/Him, She/Her, They/Them, etc.
How did you hear about us? *
Email newsletter *	Please send me the email newsletter
How do you hope to benefit from attending a cancer program, workshop, or retreat? *
Primary Cancer Diagnosis: *
Other Primary Cancer Diagnosis:	Enter diagnosis here
Original Cancer Diagnosis Date: *
Please describe the locations and extent of metastases: *
Dates of recurrence, if any:
Cancelation Policy *	I accept the cancelation policy.Cancellations 60 days or more before the event can receive a full refund – less 10% for payment processing fees and program administration. Cancellations 59-16 days before the event can receive a 50% refund. Cancellations less than 15 days before the event are non-refundable. The program registration can be transferred to another person at any time.
Virtual Programs Informed Consent & Understandings: *	I understand that Harmony Retreats Cancer Programs are an adjunctive program of stress reduction, health education, and group support that does not replace appropriate medical treatment or the care of my oncologist or physician.
Virtual Programs Informed Consent & Understandings: *	I understand that the program addresses the mental, emotional, and spiritual aspects of wellness from a non-sectarian perspective.
Virtual Programs Informed Consent & Understandings: *	I understand that Harmony Retreats reserves the right to request a participant withdraw for reasons of health, safety or the best interest of the group.
Virtual Programs Informed Consent & Understandings: *	I understand that the sessions may be recorded for clinical use only and will be destroyed after they are reviewed.
Harmony Retreats Liability Waiver *	By checking this box you (the registrant) assume all responsibility for and all risk of illness, damage or injury that may occur as a participant in a Wellness/Cancer/Health Professional Program under the auspices of Harmony Retreats, a program of Cancer Lifeline. The registrant specifically assumes all risk for injury arising while attending classes or sessions, participating in movement exercises, using equipment, while walking the grounds or inhabiting the facilities. In consideration of being accepted as a participant in Harmony Retreats programs, the registrant, on behalf of her/himself and her/his heirs or assigns, hereby releases and discharges Harmony Retreats and Cancer Lifeline, its officers, directors, employees, agents and volunteers, from all claims, demands, rights of causes of action, present or future, whether known or unknown, anticipated or unanticipated, and resulting from or arising out of an incident pertaining to the undersigned’s participation in the programs/classes. By checking this box you attest that you have read and understand this assumption of risk agreement and release and willingly and without duress, sign it on behalf of yourself and agree to be bound by it.

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