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*
Confirm Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Home Church*
If you'd like to attend a While We're Waiting Mini-Retreat for Moms at the home of Michelle Moore in Springdale, Arkansas, please choose from the options below. No lodging is available for this location.
- Please contact me if/when future events are scheduled at this location.
If you'd like to attend a While We're Waiting Mini-Retreat for Moms at the home of Joy Young in Pleasant Hill, Missouri (Kansas City area), please choose from the options below. No lodging is available for this location.
- June 5, 2021 - This event is full ... You may choose this option to be added to our waiting list.
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.
- April 17, 2021 - This event is full ... You may choose this option to be added to a waiting list.
- April 24, 2021 - This event is full ... You may choose this option to be added to a waiting list.
- July 24, 2021 - This event is full ... You may choose this option to be added to our waiting list.
- October 9, 2021 - This event is full ... You may choose this option to be added to our waiting list.
- January 15, 2022 - This event is full ... You may choose this option to be added to our waiting list.
- April 9, 2022
- April 16, 2022
- July 16, 2022
- July 23, 2022
- October 1, 2022
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?*
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, damages, or illness (including COVID-19) even if caused by negligence of While We're Waiting. I further hold harmless While We're Waiting from any claims, damages, injuries, illnesses, or losses caused by my own negligence while a guest at this 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.