Betty J. Borry Breast Cancer Adventure Weekend, Inc. dba Betty J. Borry Breast Cancer Retreats This information will be used on a need to know basis only and will be stored according to our privacy protection policy. You must have JavaScript enabled to use this form. First Name Last Name Subject Retreat: name and date Date of Birth Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone Email Emergency Contact Information Contact Name Contact phone Are you taking medications now? Yes No If so, please list meds Do you have any allergies? Yes No Drug Allergies Other Allergies (food, pollen, insect bites?) Do you have any physical handicaps, recent surgery or any other restrictions which may limit your program participation Yes No If so, what? Covid - 19 Vaccination Record 1st Dose - Vaccine name and date: 2nd Dose - Vaccine name and date: Booster Dose - Vaccine Name and date Comments CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit