Young Warrior Retreat ApplicationPlease fill out the following questionnaire to the best of your ability. *Please note that this retreat is meant for two parents/caregivers to attend with their lymphedema warrior. Child's Name * First Name Last Name Child's Date of Birth MM DD YYYY Child's Gender Parent 1 Name First Name Last Name Parent 1 Date of Birth MM DD YYYY Parent 1 Email * Parent 1 Phone # (###) ### #### Parent 2 Name First Name Last Name Parent 2 Date of Birth MM DD YYYY Parent 2 Email Parent 2 Phone # (###) ### #### Age of lymphedema diagnosis? * Area(s) where lymphedema is present? Include all areas and be specific. Is there a family history of lymphedema? Please describe the current lymphedema treatment plan? Be specific. Who is your child's current lymphedema therapist and/or what is the name of the facility or clinic? How compliant are you with the current treatment plan? Any dietary restrictions? If yes, please explain Please list any other medical conditions/issues Is there anything else we should know about your lymphedema warrior? Any physical restrictions? What are you looking to learn during your time at the PLA retreat? Please name and specify the relationship to your lymphedema warrior for all attending The cost for the retreat is $699, which covers transportation to and from the MSP airport (if needed), room on site, all meals during your stay, education sessions, bandaging kit(s), support groups. Are you able to pay today or would you like to pay a deposit of $200 today and be sent an invoice for an extended deadline? Yes, I will pay today after submitting this form. No, I would like to pay the $200 deposit today and be emailed an invoice to extend payment deadline to June 1, 2025. **Deposits are nonrefundable. Thank you!
