Breast Cancer Confirmation

I confirm that I have been diagnosed with breast cancer and all answers I will give in this application regarding treatment and diagnosis will be related to my breast cancer diagnosis only.YesNo

Treatment StatusI am currently in active treatment (chemo, radiation, cancer removal surgery) or Stage IVI have finished active treatment in the past 6 monthsI have finished active treatment in the last 6-12 monthsI am no longer in active treatment but taking maintenance therapies for an extended period of time (ex: Tamoxifen for 5 years)I am currently NOT in Active Treatment

We are sorry, you are not eligible to apply for a retreat. Little Pink Houses of Hope serves only breast cancer patients who are in active treatment at this time. We know anyone facing cancer deserves this type of vacation, but at the this time we are only able to serve the breast cancer community.

Travel Details

Little Pink has instituted a travel assistance program to help with travel expenses to the retreat location (based on securing funding). You can check https://www.littlepink.org/travel/ to view income verification guidelines. **This does not guarantee travel and does not substitute for an official application*** This information will NOT be used as part of your acceptance consideration. It is strictly to help guide us as we work to secure additional funding. DO NOT FILL OUT TRAVEL ASSISTANCE APPLICATION UNTIL YOU HAVE BEEN ACCEPTED!

I understand that if selected for a retreat, my family is responsible for any cost associated with traveling to, from and during the retreat location. Most locations require a car for the week.YesNo

We are sorry, you are not eligible to apply for a retreat. Each family is responsible for getting to the retreat location if they are selected to attend. Little Pink Houses of Hope does provides travel assistance for those who financially qualify. Each family is responsible for securing the needed transportation for the week, and most locations require a car for the week.