Camp Good Days

YOUNG ADULT WEEKEND RETREAT
We are excited to be partnering with our friends at The Young Adult Cancer Program (Roswell Park) and 13thirty Cancer Connect to host a retreat for cancer patients and survivors, ages 18 – 39 in the Buffalo, Rochester, and Syracuse areas. Please complete the below form to register for the July 7 – 9, 2023 retreat. A staff member from CGD or Roswell Park will be in touch to confirm registration and provide next steps.

* denotes a required field

*Patient First Name:

*Patient Last Name:

*Date Of Birth:

*Gender:

*Diagnosis:

*Date of Diagnosis:

*Are you currently undergoing treatment?

Yes

If no, date of last treatment:

*Institute/ Hospital where you receive care:

*Which organization are you a participant of:

	Camp Good Days
	The Young Adult Cancer Program (Roswell Park)
	13Thirty
	None, but would like to become involved.

Contact Information

*Email Address:

*Phone Number:

*Mailing Address:

*City:

*State:

*Zip Code:

Plus One: The Young Adult Weekend Retreat is open to the patient and one guest (partner, spouse, other family member or friend). Plus ones must be at least 18 years or older. Please provide their information below.

First Name:

Last Name:

Date Of Birth:

Gender:

Email Address:

Phone Number:

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