Registration Application – Mini-Retreat for Bereaved Moms First and Last Name*The Name(s) of your Child(ren) Who Died:*Your Email Address* Enter Email Confirm Email Your Phone Number*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Your Home Church*If you'd like to attend a While We're Waiting Mini-Retreat for Moms at The Refuge in Hot Springs, Arkansas, please choose from the dates below. Lodging is available at the Refuge for Saturday evening for events at this location.You may choose more than one option to be added to multiple waiting lists if you wish. July 11, 2020 - This event is full ... You may choose this option to be added to a waiting list. July 25, 2020 - This event is full ... You may choose this option to be added to a waiting list. October 24, 2020 - This event is full ... You may choose this option to be added to a waiting list. January 16, 2021 - Spots available. April 17, 2021 - Spots available. April 24, 2021 - Spots available. July 24, 2021 - Spots available. October 9, 2021 - Spots available. If you would like to attend a Mini-Retreat for Moms at the home of Michelle Moore in Springdale, Arkansas, please choose from the following options. Lodging is not provided. April 4, 2020 - Spots available. Please contact me if/when future events are scheduled at this location. If you would like to attend a Mini-Retreat for Moms at the home of Joy Young in Pleasant Hill, Missouri (near Kansas City), please choose from the following options. Lodging is not provided. June 6, 2020 - This event is full ... You may choose this option to be added to a waiting list. Please contact me if/when future events are scheduled at this location. Please tell us about your family ... including the child(ren) who died and the circumstances of the death. Include as much or as little detail as you wish.*What are you most hoping to gain by attending this retreat?*If you have any food allergies, please list those here. If not, you may leave this section blank.Do you have any accessibility or health issues of which we need to be aware? If so, please explain. If not, you may leave this section blank.How did you hear about While We're Waiting?*RELEASE OF LIABILITY: By checking here, I agree to waive, discharge claims, and release from liability the While We're Waiting ministry from any and all liability on account of, or in any way resulting from injuries and damages, even if caused by negligence of While We're Waiting. I further hold harmless While We're Waiting from any claims, damages, injuries, or losses caused by my own negligence while a guest at The Refuge or any other retreat site. I understand and intend that this assumption of risk and release is binding upon my heirs, executors, administrators and assigns, and includes any minors and/or guests accompanying me in activities associated with While We're Waiting events.*I have read and agree to the Release of Liability above.