Participant Application

November 1-3, 2024 | Latham Springs | Aquilla, TX

application deadline: August 22, 2024

* Required field

Application information

* Required fields must be filled for form to be successfully submitted

First Name

Last Name

Have you received a breast cancer diagnosis (at any age or stage)?

Have you applied to a CfR retreat before?

Have you attended a CfR retreat before?

Address

City

County

State

Zip

Home Phone

Cell Phone

Hear about CfR?

Hear About - Other

Would you like to receive CfR's E-newsletter?

PLEASE NOTE: The information gathered below is solely for statistical purposes. It will NOT affect your eligibility in any way. Your answers will help guide our outreach efforts and may increase our ability to secure grant funding.

Which of the following best describes you?

Other race/ethnicity

Do you have Stage IV breast cancer?

Are you a military veteran or active service member?

Do you have health insurance?

Have you ever needed to skip medical care? Have you ever skipped or delayed needed medical care or medications because you were unable to afford the out-of-pocket responsibilities not covered by your insurance?

Yes/No

Which of these describes your household income last year?

For office use only

2024 Application status

2024 Retreat Name

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.

Casting for Recovery ~ 109 East Oak St., Ste G ~ Bozeman, MT 59715 ~ 406-624-6583