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Bluebonnet Retreat
Bluebonnet Retreat Camper Application

Bluebonnet Retreat offers, at no charge, a unique experience for adult cancer patients. During the three-day, two-night camp, attendees are provided a creative, educational atmosphere of support with a focus on wellness.

The retreat is a special project of Texas Health Harris Methodist Hospital Hurst-Euless-Bedford.

To be considered for the camp, complete and send the form below. For more information, visit or call 817-848-4855.

* Indicates required information
Camper Information 
First Name * 
Last Name * 
Street Address * 
City * 
State * 
ZIP * 
Phone Number * 
Email Address * 
Date of Birth (MM/DD/YYYY) * 
Age * 
Sex * 
Hobbies and Interests * 
Which Session Are You Applying For? * 
Have You Previously Attended The Camp? * 
If Yes, How Many Times? 
Do You Speak English? * 
Emergency Contact 
Name * 
Relationship * 
Street Address * 
City * 
State * 
ZIP * 
Phone Number * 
Name of Physician * 
Phone Number * 
Preferred Hospital * 
List Any Known Allergies * 
Cancer Information 
Date of Cancer Diagnosis *  Calendar (mm/dd/yyyy)
Type of Cancer * 
Are You Currently Undergoing Treatment For Cancer? * 
Date of Treatment  Calendar (mm/dd/yyyy)
If Yes, Please Specify What Kind of Treatment You Are Receiving 
List Any Special Dietary Needs * 
Do You Use A Wheelchair? * 
List Any Medications You Are Currently Taking * 
Is Refrigeration Needed For Your Medication? * 
Where Did You Hear About the Bluebonnet Retreat? * 
Note: There will be no assistance for administration of medicine at Bluebonnet Retreat. 
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