On Your Feet Birthmom Retreat Application II

Retreat Application | Part 2

We are so happy you are interested in joining one of our retreats! Please complete the following 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.

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)

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?

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

Emergency Contact Information

Emergency Contact Name

Name

First Name *

Last Name *

Relationship (Required)

Relationship

Phone (Required)

Phone #

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)

qne0zomqg12g

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

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

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 impact your participation in the retreat(s)?

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 provide details:

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

Yes
No
N/A Virtual Retreat Only

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

Communicable Disease Policy and Agreement (In-Person Only)

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 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 or the flu 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 Policy and Agreement

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

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

Yes
No
N/A Virtual Retreat Only

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.