GEMBHAM Retreat Application Form

Help your Middle/High School girl become an empowered woman! In our retreat she will learn life skills and tools, helping her build strength, courage, resilience and critical thinking. She will build confidence and self-awareness in this unique retreat through inspirational and instructional guidance, outdoor group activities and art workshops. Registration is required. Minimum required age is 15. You must complete and return this application before June 15, 2025. For more information, email: contact@gembham.com

Parent’s Information

Parent’s Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Daughter’s Information

Participant’s Name

First Name

Last Name

Age

Grade for the Next School Year

School

Daughter’s Email

Daughter’s Phone

(###)

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For Participant to Complete

Tell us about your personal and academic interests and favorite activities:

What are your short and long term goals?

Why are you interested in participating in this retreat?

How did you hear about us?

Additional comments about yourself that may be helpful for us to know in order to make this experience as positive as possible:

Medical Information

Allergies (Food or other)

Medication and Dosing Information (All medication will be managed by staff upon arrival)

Name of Family Physician

First Name

Last Name

Physician’s Phone

(###)

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Emergency Contact

Name of Emergency Contact

First Name

Last Name

Emergency Contact’s Phone

(###)

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GEMBHAM Retreat Application Form

LiftUp AL Foundation