Virtual Retreat Application : Birthparent Services : On Your Feet Foundation

Virtual 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 below.

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

First Name

Last Name

My relation to the prospective retreat attendee is:

My email address is:

My phone number is:

I am applying for the:

Veteran Retreat | June 22nd
Fall Virtual Retreat | October 19th

Personal Information

Full Name

First Name *

Last Name *

Email Address (Required)

teata25ek4hh

Phone Number (Required)

Home Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Date of Birth (Required)

What is your Date of Birth?

What are your pronouns?

She/Her/Hers
They/Them/Theirs
He/Him/His
Other/Prefer not to say

If Other, please indicate your pronouns:

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

If Other, please indicate:

Are you eligible for Medicaid or Government Assistance?

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 (Spring/Fall)
Veteran's Retreats
Closed/Reunion Retreats
Birth Parent/Adoptive Parent Retreats
Virtual Retreat

Adoption History

Type of Adoption

Agency
Private/Attorney
Kinship
Foster Care

Describe your placement (open/closed/in reunion/other/etc):

Open
Semi-Open
Closed by Me
Closed by Adoptive Parents
In Reunion
It's complicated
Not Sure
Other

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)

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

Your answer will be kept confidential.

Are you currently involved with any counseling or therapeutic services?

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

I am interested in:

Please check all that apply.

Case Management Services
Working with an adoption competent therapist
Receiving a grant to attend the retreat

Veteran's Retreat Questions

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

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 have 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?

Retreat Information

Thank you for your interest in attending one of our Virtual retreats!

For all of our retreats, a number of spots are reserved for first-time attendees and a number of spots are reserved for women who have previously attended retreats. Once spots are filled, a wait-list will be started. If you are placed on the wait-list and do not get a space, you will be given priority to attend the next virtual retreat. If the spaces reserved for new attendees are not filled, the spaces will be offered to birthparents who have previously attended retreats.

The cost for an individual to attend a birthmother retreat is approximately $100; however, retreats are underwritten by On Your Feet Foundation. Because of this, On Your Feet is able to ask each birthmother to pay only $35 to attend ($25 early bird discount). If $35 is unattainable, monetary grants are available. Applicants can also make arrangements with On Your Feet staff to set up third-party payments. $25 early bird registration is available up to 6 weeks prior to the retreat.

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

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 *

Retreat Deposit and Payment

To secure your spot, we request that you pay a $10 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.