Mens Retreat Application - Glens Falls Hospital

CG
Men’s Retreat
CG Men’s Retreat Application
November 9 - 11, 2012
Christ the King
Spiritual Life Center
Greenwich, New York
Name: ____________________________________ Date of Birth: _______________________________
Mailing
Address:
___________________________________________________________________________________
___________________________________________________________________________________
Home ____________________________________ Work Phone: _______________________________
Phone:
(or cell phone)
E Mail: __________________________________________________________________________________________
Emergency
Contact:
Home
Phone:
_______________________________ Relationship:__________________________
_______________________________ Work Phone:_________________________
(or cell phone)
What type of cancer do / did you have
When were you diagnosed
Who is your oncologist
Physician’s phone number
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Which of the following treatments did you have or are receiving
 Surgery  Chemotherapy  Radiation Therapy
 Hormonal Treatment  Other _____________________________________________________
Are you currently undergoing treatment (other than preventative treatment) for your cancer
 Yes
 No
Please complete other side

What medications are you currently taking
___________________________________________________
_________________________________________________________________________________________________
What natural or complimentary treatments are you taking / receiving _______________________________
_________________________________________________________________________________________________
Do you have any special physical needs  Yes  No
If yes, please explain: ______________________________________________________________________
_________________________________________________________________________________________________
Do you have any dietary restriction  Yes  No
If yes, please explain: ______________________________________________________________________
_________________________________________________________________________________________________
Do you have any allergies (food, medicine, environmental)  Yes  No
If yes, please explain: ______________________________________________________________________
_________________________________________________________________________________________________
Have you participated in cancer support groups  Yes  No
How did you hear about the CG Men’s Retreat
___________________________________________________
_________________________________________________________________________________________________
The cost of the program is $100.00 and includes lodging for two nights, meals and activities.
Please write check to: C. R. Wood Cancer Center
There are grant funds for those who wish assistance.
Would you like a grant to fund your participation
 Yes  No
Applications must be turned in by October 31, 2012 to:
Paul Miller, RN, OCN
Oncology Education & Support Services
Glens Falls Hospital
100 Park Street
Glens Falls, NY 12801
The C. G. Men’s Retreat is limited to 15 participants and selection is determined on a first-come, first-served basis.
Individuals who have attended the Men’s Retreat in the past are welcomed to apply to this and future retreats.
However, preference may be given to first time applicants.