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? * How did you hear about Chase The Victory? * Anything else that you would like us to know? * Upload Your Application Attachments Date MM DD YYYY Consent * Media Release I, the undersigned, hereby give my permission to CHASE THE VICTORY and/or its representatives to use or publicly display our family’s photographs, audio or video recordings and to use our names, these images or voice recordings in publications, slides, videos, motion pictures or on online without further notice. I understand that these visual images and voice recordings will be used to inform families, volunteers, donors, the media and general public about CHASE THE VICTORY’S mission, programs, services and events. I gladly give this authorization to support the efforts of CHASE THE VICTORY. I understand that this authorization shall continue until terminated in writing. This form must be signed by each adult and child 18 years of age or older. Waiver of Liability and Release. I, the undersigned, hereby release and forever discharge CHASE THE VICTORY from any and all liability, claims, and causes in action, which arise or may hereafter arise or are in any way connected to our family’s involvement in a retreat. I understand that this Agreement discharges CHASE THE VICTORY from any liability or claim that we may have against CHASE THE VICTORY with respect to any bodily injury, personal injury, illness, death, or property damage that may result from involvement in a Retreat. I, the undersigned, also understand that CHASE THE VICTORY does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness. Indemnification and Hold Harmless. I hereby agree to indemnify and hold harmless CHASE THE VICTORY from any liability, claims, and causes in action, which are in any way connected to involvement in a retreat. Medical Care. I hereby release and forever discharge CHASE THE VICTORY from any liability, claims, and causes in action that arise or may hereafter arise on account of any first aid, treatment, or service rendered or not rendered in connection with a Retreat. 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!
