Participant Application

April 11-13, 2025 | KY Dam State Resort Park | Gilbertsville, KY

application deadline: January 30, 2025

* 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

2025 Application status

2025 Retreat Name

Please click the NEXT button above and then be sure you click the Submit button on the bottom of the next page. You will then receive a pop-up confirmation.

A copy of your application will be emailed to you following a successful submission.