Lung Cancer Initiative Survivor Wellness Retreat Application

2025 Lung Cancer Initiative Survivor Wellness Retreat Application

This retreat brings together lung cancer survivors who want to explore living more fully and authentically – introducing evidence-based, integrative wellness practices to serve the whole person - mind, body & spirit. Our wish is that this retreat will offer the opportunity to slow down, enjoy nature, make new friends, and focus on what is most important to you.
We are currently accepting applications for our 2025 Wellness Retreat. If you are interested in attending this retreat or a retreat in the future, please fill out the application. You will receive a personal email and phone call from Cheryl Lecroy, Lung Cancer Initiative Survivor Liaison.
Thank you for your interest in this Lung Cancer Initiative Survivor Wellness Retreat! We are excited to learn more about you and your interest in the retreat. The following are some pertinent details about the retreat:

Location: Camp La TeDa, Raleigh/Garner

Dates: September 12 – 14

Time: Friday 9 AM – Sunday 4 PM (participation across all three days is required)

Logding: Provided

Fee: No charge to attend

Open to lung cancer survivors who reside or receive treatment in NC and SC
Details of the Wellness Retreat
Throughout your restorative weekend, you will experience light body movement, explorations on themes of healing and life balance, and plenty of unstructured PLAY time (hiking, crafts, art, relaxing in the garden, and getting to know others at the retreat).

Our retreat location will be held at Camp La TeDa with hosts David Wheeler and Teri Barron. Teri is a lung cancer survivor with a wealth of healing practices to share. Also, with us throughout the weekend; Shirley Ballantyne, RN, HTP, offering Healing Touch and Gregory Whitt with experiential drumming, plus a team of wellness practitioners to support you.

Each application will be followed up with an email, and phone call, but in the meanwhile, here are the key details:
- Open to both male and female lung cancer survivors regardless of ethnicities, faith traditions and sexual orientations.
- Participants must be able to climb stairs, walk on uneven wooded landscape and handle their own daily medical needs.
- Location - Raleigh/Garner NC.
- Hotel lodging is included for Friday and Saturday
- One additional night of lodging (Thursday night) is available for those survivors who live outside of the Raleigh area and would like to avoid driving on the morning of the retreat. (optional but encouraged for those with more than a 30 minute drive)
- There are no planned activities on Thursday night and dinner will be the responsibilty of the participant.
- Transportation is the participant’s responsibility. We do try to connect fellow participants who wish to carpool, where it is an option.
- All Retreat meals are included and are whole-foods plant-based (vegetarian)
- No smoking or alcohol consumption during the Retreat.
- There will not be any wood burning bonfires and we monitor air quality for outside activities.
Again, this retreat is open to North Carolina and South Carolina residents .... and while we may not be able to accommodate and accept everyone, we do connect personally with everyone who applies!

Be sure to click the green Submit button at the bottom of the page when completed. Required fields are marked with a red asterisk. Allow 15 to 20 minutes to complete the form.

I look forward to talking with you soon!

Your host, Cheryl Lecroy
Survivor Liaison
Lung Cancer Initiative
Contact Information
Name*

First NameLast Name
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
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Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Information
Gender*
Height*
Enter your height
Weight*
Enter your weight
Age*
Enter your age
Date of Birth*
How did you hear about us?*
Tell us who referred you or how you found out about the LCI Survivor Wellness Retreat.
Relationship Status? If you have children, what ages?*
Let us know your relationship status (married, single, committed relationship, ...) and if you have children.
YesNo
If you have a sharing site, like "Caringbridge", include here (optional)
Emergency Contact Information
Contact Name & Relationship*
Enter the name of who we should contact in an Emergency AND their relationship to you (spouse, friend, etc.)
Contact Email Address*
Enter your emergency contacts' E-mail address(s).
Contact Phone Number*
Enter your emergency contacts home and/or cell #.Format: (000) 000-0000.
Oncologist / Primary Care Physician's Name*

First NameLast NameCredentials
Physician's Office Phone Number*
Enter your Physician's Office Phone.Format: (000) 000-0000.
About YOU

This section will help us get to know you a little better so that we can determine how we can best serve you.
1. Spirit / Morale - Tell us a little about your current spirit or morale.*
2. Goals - Tell us what you hope to gain from your retreat experience.*
3. Exercise - Tell us if you are currently doing any exercise, and if yes, tell us what and how often. *
4. Support - Tell us who or what are the major sources of support in your life (family, friends, religion or spiritual practice, exercise, etc)?*
5. Complimentary or Integrative Therapies - Tell us about any complementary therapies you are currently involved in (Yoga, Tai Chi, Support Groups, Healing Touch, Music, Art, PT, Acupuncture, etc.) or type "NONE".*
6. Currently Work Status - Tell us if you are currently working? And if so, the nature of your work?*
7. Previous Retreat Experience - Tell us about any previous retreat experiences or other retreats you plan to attend this year (program name and approximate date). If none, type "NONE"*
Physical Limitations

Each participant must be able to walk the equivalent of several flights of stairs and on sloped gravel/wooded paths.
1. Specific Physical Limitations - Tell us about any physical limitations that may make it difficult for you to participate in the retreat activities (wheelchair, walker, fatigue, unable to climb stairs or get up off the floor, use of oxygen tank, etc.) or type "NONE". We will talk with you more directly if any of these things are of concern to you.*
2. Neuropathy - Tell us if you are you experiencing neuropathy. If "yes", please describe. If not, type "NONE".*
3. Bones/Joints / Major Surgeries - Tell us if you have had any bones / joints removed or replaced, or any major surgeries. If so, please describe. If not, type "NONE".*
YesNo
5a. Allergies - part I - Tell us about any NON-FOOD allergies you have (drug, animal, bee,) and how severe. If none, type "NONE". *
5b. Allergies - part II - Tell us about any FOOD allergies you have (peanuts, dairy, etc) and how severe. If none, type "NONE".*
YesNo
7. Other Health Conditions - Tell us about any other health conditions or issues we should be aware of (diabetes, digestive, heart or lung conditions, sleep apnea, COPD, auto-immune deficiencies, etc.). If none, type "NONE"*
Additional Details
1. Type of Cancer - What type of lung cancer did or do you have?*
2. Stage - Tell us the current stage of your cancer (I-IV, metastatic, local, re-occurrence, etc.) and the approximate date you were first diagnosed and/or re-diagnosed*
3A. Currently in Treatment? - Tell us if you are currently in treatment and if so, how long and what kind? Or, if you have upcoming treatments or surgeries and when. (this is generally not a problem, we just need to know)*
3B. Completed Treatments? - If you have COMPLETED treatments briefly highlight what you underwent and when your treatments finished.
4. Dietary Preferences - Our healthy vegetarian menus are carefully planned. We do not serve meat, but may cook with dairy products and eggs. Please share any dietary preferences you have so we can discuss if we are able to adequately accommodate them. If no preferences, type "NONE".*
Transportation
Transportation is the participant’s responsibility. We do try to connect fellow participants who wish to carpool, where it is an option.
Next Steps
You should expect a phone call from us within 2 weeks of submission of your application. If you have NOT heard from us in that time period please email us at clecroy@lungcancerinitiative.org

Unfortunately we are not able to accept everyone due to space limitations, as well as our goal to create a diverse group for sharing purposes.

For those who are accepted, we will provide you with an Informed Consent Statement and a Tai Chi, Yoga, Healing Touch & General Liability Release form for signature, as well as directions, weather expectations, and information on what to bring.

Lung Cancer Initiative offers this retreat free of charge for survivors in hopes that participants can fully focus on healing, rather than economic concerns.

This retreat is presented with facilitation and partnership with Cheryl Lecroy of Creative Juices Consulting.
Application Signature
In submitting this application of interest to attend Lung Cancer Initiative Survivor Wellness Retreat, I state that this information is complete and accurate.
Signature of Applicant - Sign your name here as proof that all information given is complete and accurate.*

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Ensure that all required fields (marked with a red asterisk) have been properly filled out.

When complete and signed simply click the "SUBMIT" button below.

If you have problems submitting this form please contact us at: (884) 723-2442 or clecroy@lungcancerinitiative.org
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2025 Lung Cancer Initiative Survivor Wellness Retreat Application

Details of the Wellness Retreat

Contact Information

Personal Information

Emergency Contact Information

About YOU

Physical Limitations

Additional Details

Transportation

Next Steps

Application Signature

Submit