2025 Dare to Thrive Class

2027 Dare to Thrive Renewal Program Application

Thank you for taking the time to thoughtfully prepare the following application. All applications must be submitted on or before midnight on December 6th, 2026.

If you have questions about the program, please contact Beth O'Brien via email: bobrien@projectpinkd.org or call the office at 402-905-0691. The Project Pink'd office is open Monday through Thursday from 9 AM - 3 PM.

First Name

Last Name

Phone Type

Phone #

Mobile preferred for text notifications.

Phone #

Mailing Address

All retreat participants must reside in Nebraska or Western Iowa.

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Demographic and Consent Information

Birth Year ####

Birth Year

Original Diagnosis Month and Year (e.g. 03/2020)

Month/Year of Original Diagnosis

Healthcare System

What healthcare system did you receive treatment from?

If OTHER, please specify:

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I will be at least one-year post treatment(s), e.g. surgery, chemotherapy and radiation, in April 2027.

NOTE: This is from your initial diagnosis/treatment.

If you answered No to the previous question, please provide additional details (e.g. treatment dates/details).

I understand and agree that I am required to attend the entire retreat weekend experience April 23-25 2027, starting late Friday, April 23rd afternoon, through late Sunday, April 25th afternoon.

I understand and agree that I am required to participate in six (6) monthly Thriving Circles, dates to be determined.

The Retreat, private coaching and Thriving Circle sessions are highly interactive, engaging, and reflective. These sessions are professionally facilitated in an environment based on trust, openness, and respect. As a participant, I understand, and agree, that I am fully responsible for my physical, mental, and emotional well-being during the Renewal Program, including my choices and decisions.

I understand that the Renewal Program is not therapy. It is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment and I will not use it in place of any form of diagnosis, treatment or therapy.

I understand that the Renewal Program is a vehicle for achieving awareness and results but that I am the driver. Your facilitators will be a mirror for me and invite me to look at new ways of thinking and being. They may challenge my beliefs and shed new light on my actions. Your facilitators aren’t there to determine your direction or define your next steps. They will listen, observe, and support you in finding a positive and healthy way to live your life in the future.

How did you hear about Project Pink'd and the Dare to Thrive Retreat?

You and the Program

If you could change 3 things about your current situation, what would they be? Please explain.

When we see you at the end of the 6-month Renewal Program and we've met your expectations – describe what is different? What might you see, hear or experience differently?

Questions/Comments/Concerns

Sign and Submit

I acknowledge that the processes and materials used in this program are proprietary and are the property of Project Pink'd, Inc. Therefore, the content cannot be copied, shared or reused without written permission from the Project Pink'd Board of Directors.

Physical Address

Mailing Address

Dare to Thrive Renewal Retreat Application

2027 Dare to Thrive Renewal Program Application

Demographic and Consent Information

You and the Program

Sign and Submit

Our Impact In 2025

Physical Address

Mailing Address