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 AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 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. January 16, 2021 - This event is full ... You may choose this option to be added to a waiting list. 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, but you may choose this option to be added to our waiting list. October 9, 2021 - Spots available. 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.