Application For Attendance
Full Name
*
First Name
Last Name
Email
*
example@example.com
Contact Number
*
Format: (000) 000-0000.
Birthday
*
Please select a day
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Day
Please select a month
January
February
March
April
May
June
July
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September
October
November
December
Month
Please select a year
2026
2025
2024
2023
2022
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Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender/Sex
*
What are your expectations for this retreat?
*
List 1-3 areas in your life where your lack of confidence has been holding you back:
*
What areas related to ADHD and/or neurodivergence are you interested in exploring if any?
*
Do you have any previous experiences in group settings (retreats, support groups, etc.)? If so, what did you enjoy or dislike about them?
*
Are there any specific leisure activities you might like to see at this retreat?
*
Are you big on hugs or do you feel safer in your own personal space?
*
Hugs are okay.
I prefer more personal space.
Do you feel comfortable engaging in meaningful conversations about life, emotions, and past trauma?
*
Yes
No
Are you comfortable participating in (or listening to) conversations about God or Jesus?
*
Yes
No
Are there any behaviors or characteristics that you find challenging in a group setting?
*
Please list any dietary needs to be communicated to our chef:
*
Please list any physical needs that I can accommodate for you:
*
What type of room would you like?
*
Shared (Two beds) $1500
Private (One bed) $1800
Economy Shared (Two beds) $1200
Are you a "Night Owl" or an "Early Bird" (This will help me place you if you select a double bed suite)
*
Night Owl
Early Bird
Do you enjoy talking during downtime or do you prefer quiet? (This will also help me place you if you select a double bed suite)
*
Talking
Quiet
List three songs that instantly put you in a energetic/happy mood:
*
What is your favorite color?
*
Please list your favorite snacks and beverages:
*
Please list your shirt and shoe size:
*
How will you be arriving to the retreat?
*
Driving
Uber
Are you able to keep all conversations and personal information amongst the group private?
*
Yes
No
This retreat is built on mutual trust and safety. As part of my commitment to the well-being of all guests, we ask for transparency regarding any history of violent offenses or legal restrictions (such as restraining orders). I recognize that many influential individuals have complicated histories, so a "yes" does not automatically disqualify you, but it does prompt a separate, confidential conversation.
*
I confirm I have no such history.
I have information to disclose (Please provide dates and details below)
*
Emergency Contact (Name, Relationship, and Phone Number)
*
I, _________________________, hereby affirm and certify that I have provided truthful and complete answers to all questions to the best of my knowledge and belief. (Type your name below.)
*
Send
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