Splintered with Sorrow Couples Retreat - Lafayette, LA

Please keep the following information in mind:

We understand the importance of your health needs. Our team will thoroughly review your application within 3 business days to ensure we can provide the necessary accommodations. If, for any reason, we are unable to meet your needs and you've already paid, we will promptly refund your registration fee. Your well-being is our priority.

Scholarship Applications:

Upon receiving your scholarship application, our team will promptly review it for any health-related concerns. If your application is approved, our team will help secure the registration fee. Once the donation is secured, your name will be added to the retreat roster, and you will receive a warm and welcoming email.

Registration Application:

Upon receiving your registration application, we will process it within 3 business days. Our team will then review for any health-related concerns. If approved, you will receive a welcome email and welcoming email.

Parent's Information

Red Bird Ministries follows a strict confidentiality agreement. Only our RBM Team, the Assigned Small Group Leader, the Assigned Spiritual Director, and the Assigned Counselor are permitted to review your registration form. Please complete the entire registration form for registration.

I understand that my information below will not be share with anyone outside of the RBM team.

Name

This address will receive a confirmation email

Phone

Address

Health and Medical Conditions

The Red Bird Ministries team is not equipped to serve all families with confirmed mental health diagnoses or families who are medically fragile. If you have a serious mental or health condition, please let us know before you arrive so that we can determine if our team can accommodate your needs.

Please let us know if you have any food allergies, including the severity and how we can prepare food to accommodate you. In case of severe allergies, we may ask you to bring your own food if the retreat center cannot fully accommodate.

Do you have any food or environmental allergies we need to be aware of and sensitivity issues?

Are you under the medical care of a doctor with a medical or mental health condition that we need to be aware of?

Do you take any medications that may prevent you from participating in the retreat activities?

The retreat center where we hold our retreats may require the retreatant to climb a short flight of stairs. Will you be able to climb the flight of stairs a few times over the weekend?

Yes No With minimal help.

The retreat center where we hold our retreats does not have a handicap bed? Do you need assistance getting in and out of your bed?

Yes No

Emergency Contact Information

Please provide the name and contact information of an emergency contact person who is aware of your attendance and will be available to be reached during the weekend in case of an emergency. Additionally, we will send out instructions by email on how to reach us during the retreat if something happens. Please ensure that they are aware and ask them to look out for the email.

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Email

This address will receive a confirmation email

What is your relationship to the emergency contact?

Child's Information

Child's Name

Date of Birth

Date of Death

Age at Death. (If pregnancy loss, please list weeks in utero. This information is only used if we have to split a larger group into two groups to keep peers together.)

What were the circumstances surrounding your child's death?

We understand the importance of prayer, so please feel free to share a picture of your child or family here. We will use these photos to continue praying for you and your family.

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Church Parish + Diocese Information

Diocese:

Parish Name:

If you are applying for a scholarship, please provide your parish phone number here.

Who is your pastor, or the pastor that has supported you in your grief? Please share if he serves as your current pastor or family friend.

Was it a good experience? Was your pastor grief informed? RBM is dedicated to providing education and training for clergy members. Please share any insights or information to help us serve them better. RBM will not share this information with anyone and will only use it to gather information to help educate and form clergy.

Familial Relationships

Are you married, seperated, divorced, or single?

Happily Married Married, but our marriage is not good. Single Divorced Seperated

Do you have any living children?

Yes No

If you have living children, how is your relationship with your living children?

Do you need a referral for your spouse or children for professional help, or would you like information about support for your family?

Grief Journey (Get to Know Me)

Please describe how you have been experiencing your grief (e.g. crying, insomnia, emotional numbness, health issues, etc.)

Please describe how you have been coping with the loss of your loved one? (ex: taking medication, praying more, praying less, seeking therapy, overindulging in drink/food, self-harm, etc.)

Have you sought help to address your grief? What was your experience with recovery? Were you comfortable?

Have you previously attended retreats, seminars, or conferences on grief? If so, please list and explain. What is your retreat experience, if any? What were the best parts of your retreat?

What are you hoping to gain from this retreat experience? What are you searching for? What does your heart desire most?

What is one thing you would like us to know about you as we prepare for this retreat? Please list any personality traits that may best help our leaders to serve you well.

Disclaimer & Retreat Policies

Upon obtaining the appropriate releases, Red Bird Ministries, Inc. (RBMI) may share testimonies and stories of those who are grieving and anyone utilizing RBMI's resources shall indemnify and hold harmless RBMI in their efforts to support those grieving families. RBMI's support seeks to accompany grieving families in the trenches of their grief but is not intended to replace traditional therapy. RBMI does not provide online or in-person counseling or therapeutic services for a fee. Any gift or donation received directly offsets operational and program development expenses to fund these resources. If you require counseling, please contact a licensed mental health provider in your area.

To simplify: The team of Red Bird Ministries and its volunteers are not mental health providers, and all retreatants will hold harmless the ministry and its volunteers for providing a safe place for you to bring your grief. If you need mental health counseling or have a mental health disease, please seek professional counseling. Our retreats and small groups are meant to be peer-led and support those who are grieving, but never to replace traditional therapy.

I agree and consent to the above statement and will hold harmless Red Bird Ministries in their efforts to accompany grieving families.

Yes, I agree.

Registration Items

Red Bird Ministries is not equipped to handle medical or health needs. If an emergency arises and you must be taken to a doctor or hospital, we will need a copy of your health insurance card uploaded below.

If a retreatant requires medical care, contact your emergency contact. If you are from out of town, our volunteers will assist you in finding a walk-in clinic nearby.

If you need emergency medical care, RBM will call 911 on your behalf and someone will assist you to the ER.

Do you have health insurance?

Yes No

Upload Front

Upload (8MB)

Upload Back

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Red Bird Ministries is not equipped to handle medical or health needs.

If an emergency occurs and I need medical attention, I understand that I am responsible.

Refund Policy: I understand that no refunds will be given within 30 days of the retreat.

I agree to the refund policy.

FAMILY SUPPORT LIST:

Anyone who makes a purchase, or signs up for any event that we offer will be added to our newsletter email list. If you do not wish to receive any emails from us, please unsubscribe from the email list upon receiving your first email. This is an automatic process from our website platform.

I understand that I will receive newsletter event updates and support opportunities from RBM and if I do not wish to receive these further that I will unsubscribe and hold harmless RBM.

I agree to the communications policy.

Retreat Registration Fee

If you need full or partial sponsorship and choose a payment of $0 or $362.50, this form will serve as an application while we secure funds for your registration.

Once we have secured your sponsorship, we will promptly notify you and add you to the retreat roster.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Splintered with Sorrow Couples Retreat - Lafayette, LA - June 12-14, 2025

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Splintered with Sorrow Couples Retreat - Lafayette, LA - June 12-14, 2025

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