On Your Feet Birthmom Retreat Application

Adoptive & Birth Parent Retreat Application

In-Person April 14-16, 2023 | Virtual May 6, 2023

Birth Parents and Adoptive Parents who wish to attend, but are unable to attend with their child's adoptive parent or birth parent are welcome to attend individually. If you have questions, please contact Vicki.

Please indicate which retreat you are applying for:

In-Person Birth & Adoptive Parent Retreat | April 14-16
Virtual Birth & Adoptive Parent Retreat | May 6

Personal Information

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.

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)

Date of Birth

Emergency Contact Information

Emergency Contact Name

Name

First Name *

Last Name *

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Relationship (Required)

Relationship

Phone (Required)

Phone #

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

What is the highest level of education you have completed?

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, Mini-Retreat

Adoption History

Are you a Birth Parent or Adoptive Parent?

Birth Parent
Adoptive Parent

Type of Adoption (Required)

How do you describe your adoption? (Required)

What agency/attorney handled your placement? (Required)

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

Name of your child's adoptive or birth parent if they are attending the retreat with you:

In as much detail as possible, please describe your relationship with your child's birth or adoptive parent: (Required)

Retreat Questions

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

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 other programs and services? (Please check all that apply)

Birthparent Case Mangement Services
Adoption Competent Therapy
Activism in Adoption Education Series
Not at this time, thank you.

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

Medical Infomation, Allergies and Drug Use (Required for In-Person Retreat)

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

Yes
No
N/A for Virtual Retreat

Your answers will be kept confidential.

Please list any Allergies/Food Allergies/Dietary Restrictions and/or Medical Conditions (if none, please indicate by typing, "N/A"): (Required)

Allergies/Medical Conditions/Dietary Restrictions

COVID-19 Attendance Requirements

Please read the four points below in their entirety and be sure to check all that apply. Completed applications will only be considered with certification of the attestations below. Your information will be kept confidential.

Covid Policy Acknowledgment (check all that apply)

If I am experiencing 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.
I certify that I will not attend the retreat if I have a positive Covid test within 24 hours of the retreat.
I understand that if I start experiencing any Covid symptoms during the retreat, I will be required to take a Covid test. If the test result is positive, I will be required to wear a KN95 mask and social distance for the remainder of the retreat.
N/A for Virtual Retreat

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 2 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 credit towards your next retreat.

The cost for an individual to attend a retreat is approximately $600. However, the cost to you for this retreat is only $300 per birth/adoptive parent team or $100 for a birthparent and $200 for an adoptive parent attending individually. 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.

Registration Process

Retreat registration is a 3-step process. This helps On Your Feet plan retreats which optimize the attendees’ experience. This also ensures that all applicants will have sufficient support post-retreat.

Step 1: Complete the retreat registration form and, if needed, the retreat grant application. A representative will review your form(s) and contact you within 5-7 business days.

Step 2: You will be sent a retreat consent form and a Pre-Retreat Survey to complete. The survey helps us better tailor the retreat to meet everyone's needs.

Step 3: Upon receiving the completed survey and consent, an On Your Feet Retreat Facilitator will contact you to introduce herself and review the survey. Please note, registration is not finalized until the deposit is received. If the deposit is not received within 3 days of being notified of an approved application, the registrant’s spot may be forfeited.

Approximately 7-10 days prior to the weekend, attendees will be emailed a letter with detailed packing information as well as the name of their "buddy." Each new attendee will be assigned a buddy (a birthparent who has previously attended a retreat), who will contact the first-time attendee to answer any questions they may have. This will also give attendees a friendly face (or voice!) to greet them when they arrive for the weekend.

Remember, you must reserve your spot with a $50.00 non-refundable deposit. Any registration received without a deposit will not be considered complete, unless you have also completed the application for a monetary grant. If you have any questions or concerns about this, please contact Vicki or Jennifer.

Disclaimer: No alcohol or drugs are allowed at the retreat. This is a policy of On Your Feet Foundation, as well as the owners of our retreat homes. If a retreat attendee or facilitator is found with drugs and/or alcohol or using drugs and/or alcohol during the retreat, consequences may include being sent home immediately at their own expense. There will be no refunds issued. Upon discretion of On Your Feet Foundation, further retreat grants may be jeopardized.

I have read and understand the above section titled Retreat Information.

Payment

Retreat Deposit and Payment

To secure your spot, we request that you pay a $20 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.

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.
Making a monetary donation to help another birthparent attend the retreat.

Credit Card Information

Cardholder Name (Required)

Credit Card # (Required)

Expiration Date (Required)

Security Code (Required)

cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

Cover the fee associated with this online transaction?

Yes, I will pay an additional {transaction_fee} to cover the cost of this transaction.

Cover the fee associated with this online transaction?

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Payment Option

Pay Now
Pay Later

Retreat Payment

$40 Virtual Retreat Pay-in-Full
$50 Retreat Deposit
$100 Birthparent Pay-in-Full
$250 Retreat Balance
$200 Adoptive Parent Pay-in-Full
$300 Retreat - Pay-in-Full
Other

Other

Birthparent Services