Clone of 2026 HLC From Anywhere: Hear & Be Heard Retreat Registration

1

Parent / Guardian / Emergency Contact* This field is required.If your child will be using a borrowed device during the retreat, please ensure you or your designated emergency contact can be reached at the number provided during retreat hours. In an emergency, we will contact the primary contact first. Please include a secondary emergency contact as well.

Primary Parent/Guardian – Full Name

Primary Parent/Guardian – Gender

Primary Parent/Guardian – Relationship to participant

Primary Parent/Guardian – Email

Primary Parent/Guardian – Cell phone number

Text Communication Consent.

Secondary Emergency Contact – Full Name

Secondary Emergency Contact – Phone Number

2

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

3

If your child or family has previously participated in a Hope Loves Company program or event, please share which program(s) and approximately when.* This field is required.(for example: CA Camp HLC 2023, Beyond the Bunk 2023-2025, Parent Meet-Ups 2026, etc.).

4

Who is impacted by ALS in your family & what is their relation to the participant?* This field is required.

Pals First and Last Name

Pals lives or lived in home with participant

Participant is/was an active caregiver to Pals

Caregiving tasks of children

5

Is the participant's loved one currently battling ALS?* This field is required.

YESNO

6

How would you describe where the participant's loved one is in their ALS journey right now?

Recently diagnosed

Living with ALS with gradual changes

Experiencing significant progression

Receiving end-of-life care

Prefer not to share

Other

7

Please share the date your loved one passed away.

Date

8

Participant #1* This field is required.

First Name

Last Name

Participant's Email

Gender

Pronouns

DOB MM/DD/YYYY

Breakout Group Preference

Participant's Phone Number

9

Please share a bit about the participant’s personality, interests, and anything that helps them feel comfortable in group settings.* This field is required.

10

What are you hoping this retreat offers the participant at this point in their journey, and how can our team best support them during our time together?* This field is required.

11

Would you like to register an additional Retreat Participant (#2)?* This field is required.

YESNO

12

Participant #2

First Name

Last Name

Participant's Email

Gender

Pronouns

DOB MM/DD/YYYY

Breakout Group Preference

Participant's Cell Number

13

Please share a bit about the participant’s personality, interests, and anything that helps them feel comfortable in group settings

14

What are you hoping this retreat offers the participant at this point in their journey, and how can our team best support them during our time together?

15

Would you like to register an additional Retreat Participant (#3)?Please note: If you are registering more than three participants, a separate application will be required.

YESNO

16

Participant #3

First Name

Last Name

Participant's Email

Gender

Pronouns

DOB MM/DD/YYYY

Breakout Group Preference

Participant's Cell Number

17

Please share a bit about the participant’s personality, interests, and anything that helps them feel comfortable in group settings

18

What are you hoping this retreat offers the participant at this point in their journey, and how can our team best support them during our time together?

19

Will your child have access to a reliable internet connection and a device with a working camera and microphone (laptop or tablet preferred) for both retreat sessions? Participants are strongly asked to join with cameras on during group sessions to support connection and engagement, unless otherwise discussed with facilitators in advance.* This field is required.If access to a device or reliable internet may be a barrier, please reach out. We are happy to talk through possible solutions together.

20

Is there anything else you would like our team to know as we prepare for the retreat?

21

Today's Date * This field is required.

Date