Apply to Attend a Chase The Victory Family Retreat Which type of retreat are you interested in attending? * Family Retreat Marriage Retreat Apply for a Chase The Victory Retreat due to: * The loss of a child to childhood cancer. The loss of a child age 21 and under to other circumstances. Our Family Name (Example: The McDaniel Family) * In Memory of our child: * Date of Birth * Date of Death * Age at Death * Cause of Death * Diagnosis * Age at Diagnosis Primary Hospital * Primary Oncologist * Chase The Victory Retreats * Check all that apply Select my family for any available opening on a Chase The Victory Retreat February 16-21, 2025 (Family Retreat) April 6-11, 2025 (Family Retreat) June 8-13, 2025 (Family Retreat) June 13-15, 2025 (Marriage Retreat) June 17-22, 2025 (Family Retreat) November 7-9, 2025 (Marriage Retreat) Parents's Names * Which parent is submitting this application? First Name Last Name Are you Married? * Number of Years Married Mother's Birthday * Father's Birthday * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Mom's Phone Number * (###) ### #### Dad's Phone Number * (###) ### #### SIBLING INFORMATION Do you have other children? * Yes No Sibling #1 Name First Name Last Name Sibling #1 Age Sibling #1 Birthday Sibling #1 Gender Sibling #2 Name First Name Last Name Sibling #2 Age Sibling #2 Birthday Sibling #2 Gender Sibling #3 Name First Name Last Name Sibling #3 Age Sibling #3 Birthday Sibling #3 Gender Application Questions How has the loss of your child affected your marriage? * How has the loss of your child affected your other children? * Are you a part of a church? * Yes No What is the name of your church? Are you involved with any other organization, group, or support system? If so, please list them here. * How important is it for your family to attend a Chase The Victory Retreat? * Anything else that you would like us to know? * Upload Your Application Attachments Date MM DD YYYY Consent * Yes, I consent to the above. I agree to the Media Release, Waiver of Liability and Release, Indemnification and Hold Harmless, and Medical Care Release Thank you!
