2027 Participant Application Pre-check Form

Applicant Information

First Name

Little Pink Houses of Hope Retreats

While attending a Little Pink Houses of Hope Retreat, families build hope, grow closer together, and find joy in a caring and supportive community. If you are ready to have fun, relax and connect with others, this Retreat is for you!

Who Can Apply?

If you have attended a Little Pink Retreat previously, you are not eligible to apply or attend again.

You may be eligible to apply if you:

* Have a current diagnosis of Breast Cancer.

* Are currently receiving primary treatment for Stage 0 - III Breast Cancer or are receiving ongoing treatment for Metastatic (Stage IV) Breast Cancer.

* Are under the care of a licensed oncology provider.

* Are ambulatory or travel with a caregiver who can assist with mobility needs.

* Are an adult diagnosed with Breast Cancer.

Please Note: Little Pink Houses of Hope retreats are designed exclusively for individuals diagnosed with Breast Cancer and the loved ones who support them.

Application Prioritization - Because Retreat availability is limited, eligible applications are prioritized based on where applicants are in their Breast Cancer journey.

Priority is Given to - Individuals currently receiving primary treatment for Stage 0 - III Breast Cancer and individuals receiving ongoing treatment for Metastatic (Stage IV) Breast Cancer.

Who Can Come with Me?

You can bring people who live in your home or your primary caregiver. These are the people who have been most affected by your diagnosis and for whom our program is designed. Differences or changes in who may come with you are exceptions and are approved in a case-by-case review.

We Welcome:

* Couples

* Families

* Single Participants

If you are Single, you may bring a caregiver, family member, or close support person. We know every family is different and will consider special situations. Retreats are meant for your immediate household, not extended family reunions.

Little Pink Houses of Hope welcomes service dogs as defined by the Americans with Disabilities Act (ADA)

Because our Retreats are hosted in privately donated properties, service dogs must be disclosed during the application process so appropriate planning can occur.

Emotional support animals, comfort animals, therapy animals, and pets are not permitted on retreats.

Where Will We Stay?

Each Family will be housed in your own private condo or house, donated by a private owner for your use. Your unit is selected based on your family information. Most donated units are 2-4 bedrooms. Most units have all the amenities of a usual home - washer/dryer, kitchen, Wi-Fi, etc. Property owners and managers, and thus Little Pink, have strict rules about no smoking or vaping of any substance, legal or illegal, within 25 ft of the property. Any smoking of any kind within a property is grounds for immediate dismissal from the property and the Retreat.

What Does Little Pink Provide?

Little Pink Houses of Hope Provides:

* A Private Vacation Home for your family during your Retreat.

* One planned meal and one scheduled activity each day.

* A gift card to help offset incidental expenses during your Retreat.

What You Are Responsible For:

* Transportation to and from the Retreat Location.

* Transportation throughout the Retreat Week (your personal vehicle or a rental vehicle is recommended).

Please Note that most Retreat Locations have limited or no access to rideshare services (such as Uber or Lyft).

Travel Assistance may be available for families who demonstrates financial need and meet eligibility requirements.

Do I Have to Attend Every Activity?

No. Your Retreat is intended to provide time for both connection and rest. Participation is scheduled meals and activities is encouraged but not required.

The only events that all Retreat Participants are expected to attend are the Welcome Dinner at the beginning of the Retreat and the Closing Dinner at the end of the Retreat. These gatherings help create a sense of community and allow families to connect with one another.

Can I Attend Part of the Week?

No. Retreats are designed for families who can attend the entire week so everyone can enjoy the full experience.

Participants are Expected to:

* Treat homeowners, volunteers, staff and other families respectfully.

* Care for the Retreat home.

* Follow Retreat guidelines.

* Notify Staff if an Emergency arises.

How To Apply

* Applications are accepted online only.

* You only need to submit ONE Application for each Retreat Year.

* Your Application stays active for the entire Retreat year.

* Before Applying, choose Retreat Locations and Dates that fit your travel plans, school schedules, and other commitments.

When Will I Hear Back?

Retreat invitations are made on a rolling basis usually 2-3 months before the Retreat.

Because we receive more Applications than available Retreat spaces, only applicants selected will be contacted. If chosen, you'll receive an email, text and phone call with next steps. You'll also need to complete a few forms , including medical verification from your oncology care team, before your spot is confirmed.

I understand that it is my responsibility to provide accurate contact information, monitor my email (including spam/junk folders), text messages, voicemail and respond promptly if I am contacted by LIttle Pink Houses of Hope regarding my application or retreat invitation.

Questions? Email: retreat@littlepink.org

Diagnosis Verification

I certify that I have been diagnosed with Breast Cancer. I understand that if any information provided in this Application is intentionally false or misleading, Little Pink Houses of Hope may discontinue my application or revoke my eligibility for current and future Retreats.

Which Best Describes your Current Breast Cancer Treatment Status?

Please Select the Option that best describes where you are in your Breast Cancer Journey - Select 1

A. I have Metastatic (Stage IV) Breast Cancer and am currently receiving ongoing treatment or medical management. (Examples may include chemotherapy, radiation therapy, immunotherapy, endocrine therapy, alternative therapies, or other treatments prescribed by your oncology team.)

B. I have Stage 0 - III Breast Cancer and am currently receiving or scheduled to receive my primary course of treatment. (Examples may include surgery, chemotherapy, radiation therapy, immunotherapy, targeted therapy, or other treatments that are part of your initial treatment plan.)

C. I have Stage 0 - III Breast Cancer, have completed my primary treatment and am receiving long-term hormone or endocrine therapy (such as tamoxifen or an alternative inhibitor).

D. I have Stage 0 - III Breast Cancer and have completed all planned treatment and am no longer receiving treatment or ongoing medical management for my Breast Cancer.

Please Select the Timeline that best fits your Current Situation - Select 1

Current Active Treatment/Metastatic (surgery, chemotherapy, radiation therapy, immunotherapy, targeted therapy, or other treatments that are part of your initial treatment plan, diagnosed in pre-treatment)

0-6 Months Post-Active Treatment (surgery, chemotherapy, radiation therapy, immunotherapy, targeted therapy, or other treatments that are part of your initial treatment plan.

7-12 Months Post-Active Treatment (surgery, chemotherapy, radiation therapy, immunotherapy, targeted therapy, or other treatments that are part of your initial treatment plan.)

Not Sure which option applies to you? We understand that every Breast Cancer journey is unique. If you are uncertain which category best describes your current situation, please contact Little Pink Houses of Hope before completing your application. We're happy to help determine your eligibility.