Preferred Family Healthcare Preferred Family Healthcare and Spark of Life are partnering to offer Grief Recovery Retreats to PFH employees and their families. Register below if you are an employee of PFH and desire to attend a Spark of Life Grief Recovery Retreat. STEP ONE-Select Your Retreat Please select the retreat you want to attend. Retreats may fill up early. Your registration spot is NOT GUARENTEED until we receive the $500 refundable no-show deposit. You will receive a confirmation email once we receive your deposit. Choose retreat date below: * Oct 12-15 (Eureka Springs lake house) waiting list If your retreat is full do you want to be put on the waiting list? * yes no If your retreat is full are you willing to travel to another retreat option? * yes no Choose your second retreat date below that you are willing to attend: October 20-23,2016. NOW FULL STEP TWO-Your Info Primary Registrant First Name * Primary Registrant Last Name * Primary Registrant Email: * Primary Registrant Phone: * Primary Registrant Mailing Address: * Primary Registrant City: * Primary Registrant State: * Primary Registrant Zip: * Primary Registrant Age * 18-29 30-39 40-49 50-59 60 above How did you hear about Spark of Life? It's My Heart American Foundation For Suicide Prevention Internet Search Friend Past retreat participant Do you have any dietary restrictions? * yes no If yes please specify. Do you have any issues with climbing stairs? * yes no Tell us about Your Loss Experience: * Please briefly describe your reason for desiring to attend. This will help us to better prepare for your retreat experience. Please provide the name of a supportive relative or friend below: Please give us the name of a friend or relative NOT ATTENDING the retreat, who knows you are coming and is supportive of your situation. Your supportive Contacts Name: * Your supportive Contacts Relationship to you: * Your supportive Contacts Phone in case we need to reach them : * Your supportive contacts Email Address (Please do not use your email address) : * STEP THREE- Your roommate information Is a spouse, family member or friend attending with you? * no yes If you answered yes above, what is their relationship to you? Spouse Child Sibling Family Member Friend Other Are you willing and able to share the same lodging room with them? yes no If you share a room; will you also share a bed? ex: queen room yes no Roommate Info Please provide all information specifically for your roommate. Roommate First Name Roommate Last Name Roommate Email: Roommate Phone: Roommate Mailing Address: Roommate City: Roommate State: Roommate Zip: Roommate Age 18-29 30-39 40-49 50-59 60 above Does roommate have any dietary restrictions? yes no If roommate has dietary restrictions please specify. Does roommate have any issues with climbing stairs? yes no Roommates Loss Experience: Please briefly describe your reason for desiring to attend. This will help us to better prepare for your retreat experience. Please provide the name of a supportive relative or friend of roomate below: Please give us the name of a friend or relative NOT ATTENDING the retreat, who knows you are coming and is supportive of your situation. Relationship to your roomate: * Your roommates supportive friends Phone in case we need to reach them : * Your roommates supportive friends Email Address: * STEP FOUR- Misc Info Are there any others coming with you we should know about that need their own room? Please list names below of others attending with you that require their own separate room. THEY WILL NEED TO FILL OUT THEIR OWN REGISTRATION FORM TO ATTEND. Please ask them to fill out their own registration form. Please list comments or additional information that will help us process your registration .