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 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 - 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 - Spots available.
- July 24, 2021 - Spots available.
- 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?*
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.

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