On Your Feet Birthmom Retreat Application

In-Person Retreat Application

We are so happy you are interested in joining one of our retreats! Please fill out the application to the best of your ability. You will need to complete the "required" sections in order to submit the application. There are no right or wrong answers. If you have questions, please reach out to Vicki or Jennifer.

Please Note: This application should be completed by the prospective attendee. If you are completing this application on behalf of someone else, please indicate at the bottom of this form.

I am completing this application on behalf of someone else. My name is:

First Name

Last Name

My relation to the prospective attendee is:

My email address is:

My phone number is:

I am applying for:

Traditional Virtual Retreat | Saturday, February 8th (10-3 CST)
Closed/Reunion Virtual Retreat | Saturday, April 26th (10-3 CST)
Closed/Reunion In-Person Retreat | September 26-28
Traditional In-Person Retreat | November 7-9

Personal Information

Please note, In order to be eligible to attend a retreat, you must have given birth to and placed a child for adoption.

Full Name

First Name *

Last Name *

Email Address (Required)

Phone Number (Required)

Home Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Date of Birth (Required)

What are your pronouns?

She/Her/Hers
They/Them/Theirs
He/Him/His
Other

Please list your pronouns if not listed in the options above:

Race/Ethnicity (Please check all that apply):

Black/African American
Hispanic/Latino
Asian
Native Hawaiian/Other Pacific Islander
Indigenous Peoples/First Nations/Inupiaq/Inuit
White/Caucasian
Other/Prefer not to say

Are you eligible for Medicaid or Government Assistance?

What is the highest level of education you have completed?

Emergency Contact Information

Emergency Contact Name

Name

First Name *

Last Name *

Relationship (Required)

Relationship

Phone (Required)

Phone #

Retreat Experience

Have you attended an On Your Feet Retreat before?

If you have attended an On Your Feet Retreat in the past, please list the type of retreat(s) and the year(s) attended.

Traditional, Virtual, Veteran's, Closed/Reunion, Adoptive Mom/Birthmom

Adoption History

Type of Adoption

Agency
Private/Attorney
Kinship
Foster Care

How do you describe your placement?

Closed
In Reunion
Semi-Open
Open

What agency/attorney handled your placement? (Required)

Name(s), DOB and Placement Date of Child(ren) Placed (Required)

Do you feel the placement was your choice?

Yes
No
Other

Are you parenting?

If you are currently parenting other children, please list their name(s) and age(s):

Retreat Questions

Why would you like to attend an On Your Feet Retreat? (Required)

rttpfq368rrf

What do you hope to get out of the retreat? (Required)

What type of post-retreat support will you have? Please explain. (Required)

Are you currently involved with any counseling or therapeutic services?

Are you interested in learning more about On Your Feet's Case Management services, including our counseling grants?

Yes
No
I'm not sure.

Please provide any additional information, if any, that you would like us to know:

Veteran's Retreat Questions

If you are applying for the Veteran's Retreat, complete this section. If you are applying for either the Spring or Fall Traditional Retreat, please move on to the next section.

How would you describe your adoption journey to this point?

What particular issues/struggles in your adoption would you identify as your most difficult right now?

Please tell us about any steps you taken to promote your own personal growth. (Examples may include: regular activities for self-care, individual or group therapy, any other supports/pursuits)

What are your future goals for your adoption relationships?

Medical Information, Communicable Disease/Covid-19, Allergies and Drug Use

Are you using/have you used illegal drugs within the past 6 months?

Your answers will be kept confidential.

Do you have a diagnosed condition (physical or mental) that may limit or impact your participation in an in-person retreat?

This information will not be considered for eligibility, but helps us to provide any needed accomodations in order to ensure the best experience for everyone.

If you answered yes, please describe:

Do you have any food allergies or restrictions that we should be aware of?

If you answered yes above, please list any Allergies/Food Allergies/Dietary Restrictions (if none, please indicate by typing, "N/A"):

Communicable Disease/Covid-19 Policy and Agreement

On Your Feet Foundation has put in place preventative measures to reduce the spread of communicable diseases. However, we cannot guarantee that our retreat attendees will not become ill. To help reduce the risk of spreading an illness, please read and adhere to the following.

As a retreat attendee, I will comply with On Your Feet's Communicable Disease/Covid-19 Policy:

1. If I am experiencing any signs of a communicable disease, including any of the following symptoms within 48 hours of the retreat, I agree that I will not attend: cough, fever, chills, body aches, shortness of breath, loss of taste/smell, nausea/vomiting/diarrhea, stuffy/runny nose.

2. I certify that I will not attend the retreat if I test positive or if I have come into contact with someone who has tested positive for Covid-19 within 10 days prior to the start of the retreat.

3. I understand that it is in my best interest to stay home when in an infectious state to protect not only myself, but others at the retreat. Further, I understand that I will not be able to participate in the retreat in a meaningful way if sick. I understand that staying home helps prevent the spread of illness and will allow myself time to rest and recover.

If you have any questions or concerns, please reach out to Jennifer.

Communicable Disease/Covid-19 Policy and Agreement

Click here to indicate that you have read and agree to comply with all 3 points presented in our Communicable Disease/Covid-19 Policy.

Retreat Registration Information

**Please Read**

Thank you for taking the time to fill out our application! We are excited for you to learn more about our Birthmother Retreats.

We reserve a number of spots for first-time attendees. Once spots are filled, a wait-list will be started. If the spaces reserved for new attendees are not filled, the spaces will be offered to applicants who have previously attended retreats.

Registration closes 8 weeks prior to the start date of the retreat. On Your Feet will try their best to inform a “wait-listed” registrant one month prior to the retreat confirming whether or not she has a spot (to allow for budgeting, communicating with work, and to make transportation arrangements). If you are placed on the wait-list and do not get a space, you will be given priority to attend the next retreat.

If you are approved to attend the retreat, but have to cancel due to illness or exposure to someone who has tested positive for Covid-19, you will be given priority to attend the next in-person retreat. You will be eligible for a refund or a credit towards your next retreat.

The cost for an individual to attend a birthmother retreat is approximately $600. However, On Your Feet only asks attendees to pay a discounted rate of $100 (early bird pricing) or $125 (for registrations after the Early Bird Deadline has passed). We recommend planning in advance. This is a great way to take control of and prioritize your own well-being. If the discounted amount is unattainable, grants are available for applicants who demonstrate financial need. Applicants may also make arrangements with On Your Feet staff to set up third-party payments.

Transportation assistance (arranging carpools, help getting to/from train station and airports, etc.) is also available. Registrants are responsible for the cost of their transportation to/from retreats.

Retreat Attendance Policy

On Your Feet retreats are a safe space for everyone involved - facilitators and participants. With that in mind, we ask that everyone attending the retreat please adhere to the following policies. Failure to do so may result in dismissal from the retreat at the attendee's own expense and/or ineligibility to attend future in-person events/retreats.

1. Do not attend the retreat if you are sick. If you have been exposed to Covid-19, or any other communicable disease/virus within 14 days of an in-person retreat/event, you must have a negative test within 24 hours of attending. If you have a positive test or have symptoms including fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea, you will not be permitted to attend. If you develop symptoms during the retreat, you will be required to wear a KN95 mask and maintain social distancing for the remainder of the retreat.

2. This work is best done sober. Alcohol and drugs, without a valid prescription, are not permitted at the retreat. Please arrive at the retreat sober.

3. Weapons are not allowed. Weapons of any kind are forbidden on the retreat premises, including in vehicles parked on retreat property. There are no exceptions to this policy and anyone found in violation will be excluded from all future in-person events.

4. Know your rights. When traveling, please be mindful of state and federal laws regarding traveling with controlled substances and/or weapons. On Your Feet is not responsible for nor will the organization be able to provide assistance to anyone who violates state or federal laws. If you are detained for violation or suspicion of violation of any state or federal laws, you will not be eligible for reimbursement for the cost of the retreat or travel expenses.

I have read and understand the above section titled Retreat Registration Information, including the Retreat Attendance Policy. I agree to adhere to these policies.

I am interested in:

Please check all that apply.

Receiving financial-assistance in order to attend.
Receiving help arranging transportation.
Providing transportation to another birthmom in my area.

Release of Information

This release does three basic things: it gives us permission to contact your agency, whom we depend on for referrals; it allows us to use your non-identifying information in our statistical analysis to evaluate the effectiveness of our services and to obtain funding from donors; and it enables us to collaborate as a team to provide the best services to you. I, name entered below, give permission to On Your Feet Foundation to exchange or release information regarding adoption services. I also give permission for On Your Feet Foundation to contact references and the adoption agency that provided services during pregnancy and adoption placement. I am aware that On Your Feet Foundation is in the process of gathering research data and some of the statistical information gathered may be used for research. I am also aware that signing this release allows my adoption story to be shared in likeness in the On Your Feet Foundation printed materials and/or website/social media pages. No confidential data or identifying information such as names and addresses will be used for this purpose. By signing this release, I understand this allows all pertinent On Your Feet Foundation personnel/staff to collaborate on my behalf as a team, to provide the best services deserved to me.

Signature:

First Name *

Last Name *

Payment

Retreat Deposit and Payment

To secure your spot, we request that you pay a $25 deposit (this does not guarantee acceptance of your application, but secures your place while your application is reviewed). Once your spot has been confirmed, you will be notified by On Your Feet on how to pay the balance. If you have applied for a retreat grant, please wait until you have confirmation from one of our case managers regarding the total amount due. If you are interested in learning more about our need-based grant, please check the box below and a staff member will be in contact with you shortly.