2235 Encinitas Blvd., #107b
Encinitas, CA 92024
www.angelfaces.com
info@angelfaces.com
LEVEL 2 RETREAT APPLICATION
RETREAT DATE:
June 20 - 26, 2016
LOCATION OF RETREAT:
Wolfeboro, New Hampshire
APPLICATION DUE DATE:
March 15, 2016
RETREAT COST:
No cost to participant. The retreat cost of $4,500 per girl is
paid by Angel Faces donors.
APPLICATION FEE:
TRANSPORTATION:
$150 Application fee (should be raised by applicant herself)
A limited number of airfare scholarships are available. We
encourage applicants to seek a sponsor (hospital, burn
foundation, firefighter association) or to hold a fundraiser.
Angel Faces offers the only week-long retreat in the United States for young women, ages 10-29, with facial differences
or large body surface scarring due to burn or trauma-related injuries. Since 2003, Angel Faces has offered these holistic
retreats that focus on the psychosocial needs of the attendees. Angel Faces was the first organization to offer this kind of
healing retreat, which differs significantly from burn camps.
Applications are prioritized based on demonstrated commitment to healing and giving back to the community. Attendees
are allowed to attend more than once, but no more than three times. The deadline for submitting applications is March
15, 2016.
Angel Faces’ Level II retreat is open only to young women who have participated in the Angel Faces Level I retreat.
Level II provides leadership and mentorship training with emphasis on self-awareness, self-management, social awareness
and relationship management. Attendees engage in interactive experiences, learning sessions, group discussions and
physical activity. Young women learn skills that build upon and sustain the foundational lessons learned in Level I
experiences, and prepare them to mentor and lead in future retreats and in the community.
Attending the Level II retreat is a privilege that comes with responsibilities. Level II participants are required to serve as
mentors for a year following the Level II retreat. This year-long mentorship will require weekly emails and social media
interaction with possibly two Level I participants. Level II participants are also required to be active participants in the
Angels in Flight program, sharing posts regularly, commenting on others’ posts, and participating in at least quarterly
Skype sessions with the group. We will provide training and guidelines for the year-round mentorship.
To be accepted to the Level II retreat, you must:
 Have completed at least one Level I retreat.
 Be at least 18 years of age.
 Be interested in becoming a leader in Angels in Flight and elsewhere in their community.
The Angel Faces nonprofit organization is led by Lesia Cartelli, who endured a serious burn injury as a child. It is
supported by two staff members, two part-time licensed psychologists and a dedicated volunteer team of professionals.
Pre- and post-test results show that attendees to Angel Faces retreats experience favorable psychosocial adjustments:
Increase in hope; decrease in depressive symptoms; and increase in quality of life. A poster summarizing the 2010
research findings won awards at the American Burn Association conference.
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Applications are available for download at www.angelfaces.com. Applications must include a close-up photo of the
applicant (which the corrective cosmetics team will use to determine individual needs for the private consult).
Applications also must include a fee of $150.
The per-girl cost of the week-long retreat is $4,500 (not including airfare) and that is covered by Angel Faces donors.
Attendees are encouraged to reach out to their local community groups, church, burn foundation, medical professionals,
and firefighter associations for financial assistance for the airfare. Development director Sharon Jones at 760-230-1276 or
sharon@angelfaces.com will provide guidance, if needed. Angel Faces is a nonprofit that receives donations from
individuals, foundations and corporations. Our tax ID number is 20-5718594.
Send the completed application, a headshot, and application fee of $150 to:
Angel Faces
2235 Encinitas Blvd. #107b
Encinitas, CA 92024
Or email: terry@angelfaces.com
If you have any questions, please contact us at terry@angelfaces.com or (760) 487-1720.
We look forward to receiving your application!
Sincerely,
The Angel Faces Team
LESIA CARTELLI
FOUNDER/CEO
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TERRY HEWITT
PROGRAM COORDINATOR
SHARON JONES
DEVELOPMENT DIRECTOR
2235 Encinitas Blvd., #107b
Encinitas, CA 92024
www.angelfaces.com
info@angelfaces.com
June 20-26, 2016
LEVEL II
Participant Application
You can fill this form out electronically in MS Word; move to the different fields by hitting the “tab” key on your keyboard. USE AS
MUCH SPACE AS YOU NEED FOR YOUR ANSWERS. The field will adjust.
Participant’s name:
Participant’s age (at the time of the retreat):
Submitted by:
Relationship to participant:
Name of referring health care provider:
Participant Phone:
Participant Email:
How many times have you attended an Angel Faces
retreat? What years did you attend?
How many Angels In Flight Skype sessions have you
attended? How has attending helped you? If you
have not attended, please explain why. Going
forward, Angels in Flight participation is required
of retreat participants.
Application Checklist
Completed and signed application
$150 Application Fee
Current close up facial photo MUST BE ATTACHED
Complete the form in word and email back to Terry Hewitt: terry@angelfaces.com Be sure to attach a
CLOSE UP PHOTOGRAPH (without Makeup) Or maile to Angel Faces, Attn: Terry Hewitt, 2235
Encinitas Blvd. Suite 107b, Encinitas, California 92024
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2235 Encinitas Blvd., #107b
Encinitas, CA 92024
www.angelfaces.com
info@angelfaces.com
Level II
Participant Application
Part One: COMPLETE this form out electronically in MS Word; move to the different fields
by hitting the “tab” key on your keyboard.
Participant UPDATED Information
Participant’s
Name:
Participant’s
Cell Phone:
Participant lives
with:
Participant’s Date of
Birth:
Participant’s Age
during the 2016
retreat:
Participant’s Email
Address:
Home Address:
City, State, Zip
Name of your
Employer:
Position/Title:
Employer’s
Address:
Employer’s Phone
Number:
Does this employer
match employee
donations to nonprofits?
Participant’s marital status?
Emergency Contact Information
Name of Emergency
Contact:
Home Phone Number:
Relationship:
Cell Phone:
Health/Mental Status
Current Medications
1.
2.
3.
4.
4
Dose
Allergies?
(food,
medication
or other):
Are you in bandages? Where? If so,
please explain/describe.
Are you wearing pressure garments or
splints?
Do you have hearing or vision
problems? Please explain.
Have you received any psychological
counseling since the last retreat? If so,
when?
Current therapist name and contact
information.
Have you attended any support groups
or camps in the past 30 days?
Burn Camp and Role you played
No
Yes:
No
Yes
No
No
Yes
No
Location
How old were you when you attended
an Angel Faces retreat(s)?
How many years (or months) after
your accident did you attend?
What did you gain from the last
retreat? How did it help you?
Have you noticed a difference in how
you handle your facial/body difference
socially since you’ve attended an Angel
Faces retreat? Please explain:
Have you received reconstructive surgery in the past
6 months? If so, when was the most recent? What
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If yes, how
recent:
Wearing
schedule:
Date
surgery was done?
Is there currently legal action pending regarding
this injury, trauma, or abuse? Are there any
depositions pending? Please explain if necessary.
Signature
Date:
Signature of Witness:
Date:
Part Two:
Please take the time to sit quietly and share with us “who you really are”. Your answers are confidential. So let go, let loose and
write away!
1. Give specific reasons why you feel you would be a good Candidate for the leadership program, Level II.
2. What tools, skills have you learned in the past from Angel Faces?
3. What changes have you made in your life since attending Angel Faces?
4. How would attending Level II this summer contribute to your own personal and professional growth? What do
you hope to gain from the retreat?
5. What to you are the qualities that define a leader and a role model?
6. Have you stayed in contact with any girls you met at the retreat? If yes, how do you communicate? How often
do you communicate?
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7. What areas in your life do you need more help with?
Make-up
Teasing
Stares
Family
Talking to Boys
Dating (or lack of)
Making Conversations
Socializing
Other:
Give examples of your answers (from above):
8. How do you spend now your free time now? Hobbies? Interests? Sports?
7. I avoid social situations when: (check all that apply)
There will be new people around
When boys are present
When children are around
Other:
If I need to change clothes
8. Living situation:
With whom do you live?
9. Please give 3 examples of situations where someone stared at you and how you handled it.
10. What is your biggest concern for your future?
11. What does mentorship mean to you?
12. Who is your mentor? Why?
13. Name three regrets?
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14. Are you attending college now? If so, where and which school, what level are you in? If not, explain why,
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15. Describe the strongest relationship in your life right now. Could be your mother, father, sister, brother,
boyfriend, grandparents, friend. Describe your most challenging situation.
16. How do you handle media and interviews? Are you comfortable with them?
Additional Comments: Use this space for other information you would like to share.
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2235 Encinitas Blvd., #107b
Encinitas, CA 92024
www.angelfaces.com
info@angelfaces.com
Media Release Form
(To be read and signed by participant)
Dear Participant,
The continued success of Angel Faces relies heavily upon the ability to sustain funding. In order to continue
and expand the program, maintain and seek new supporters, we must share our vision in a variety of ways. This
includes but is not limited to; video presentations slide shows, newspaper or magazine articles, descriptive
brochures, television or radio programs, and photographs.
You are not required to give permission for publicity release. We do, however request that you sign for the
possibility to involve yourself in publicity opportunities should the occasion present itself during the retreat or
while representing Angel Faces. Angel Faces facilitators will monitor media and printed materials to the best of
our ability to encourage appropriate representation of the retreat participants.
Angel Faces is known for its harmonious, tranquil and healing environment. We reserve the right to send home
immediately any participant from the retreat that is troublesome, violent, threatening or disruptive to the
program, other participants, volunteers or the facility. The travel home will be at the expense of the
parent/guardian. This includes a zero tolerance policy for smoking, alcohol, and non prescription drugs.
Sincerely,
Angel Faces Facilitators
I hereby give permission for my child to be videotaped, photographed, or recorded for use in publicity as
described in the above paragraph.
Signature of Participant:
Name Printed:
10
Date:
2235 Encinitas Blvd., #107b
Encinitas, CA 92024
www.angelfaces.com
info@angelfaces.com
Consent and Waiver
(To be read and signed by participant)
1. Medical Services: I hereby give permission to Angel Faces to follow routine treatment or to select qualified
personnel to care for me as directed by written instruction from my doctor or caregiver.
2. General Services: I hereby give permission to the Angel Faces facilitators or someone directed by him/her,
to provide me with emergency medical services, transportation, housing, and meals associated with my
registration as a participant. Additionally, I hereby agree that in the event that services or medical treatment is
needed other than provided at the workshop, I accept full and complete responsibility.
3. Personal Property: I understand that the Angel Faces facilitators will make reasonable efforts to assist the
participants in caring for their personal belongings. I hereby agree that Angel Faces will not be held responsible
for the participant’s lost or damaged personal property.
4. Risk of Serious Injury: I hereby understand that some activities may take place away from the workshop
location and release all places/resorts that Angel Faces® attends from any and all liabilities due to serious
injury, including paralysis and death due to participation at these locations. I voluntarily and knowingly
acknowledge, accept and assume the risk, except that which is result of gross negligence or wanton willful
misconduct.
5. Authorization of Treatment: I, the participant, authorize Angel Faces to act if I am a victim of accident,
injury or illness when immediate medical or surgical care is needed.
Signature of Participant
Name Printed:
11
Date:
Angels in Flight Agreement
***By signing this form the participant affirms having read it***
By submitting this Level II Retreat application, you are seeking to engage more deeply in your participation in
the Angel Faces community, helping adolescent girls who have been through trauma achieve full healing and
reach their optimum potential. Your acceptance to participate at Level II is a privilege that comes with
responsibilities.
All women who participated in the Level II retreat are expected to participate in Angels in Flight, an online
support group that reinforces skills and tools learned at the retreat. We believe that the Angels in Flight support
community is very important to the healing process. All Level II participants are also required to mentor at least
two Level I participants for one year.
In submitting this application, ____________________ (print applicant’s name) agrees to do the following if
__________________ (print applicant’s name) is accepted to participate at a Level II retreat:
1)
2)
3)
4)
5)
Attend at least four Angels in Flight video conference sessions during the year following the retreat.
Read the e-newsletter issued each month, for a year following the retreat.
Respond to any evaluation or survey requests from Angel Faces (at most twice a year).
Participate in Angels in Flight social media groups for 12 months following the retreat.
Communicate monthly with your assigned Angel Faces mentoree for a year following the retreat.
Signature of Participant
If you enter your name electronically, you are
legally signing this Consent and Waiver. You
agree your electronic signature is the legal
equivalent of your manual signature on this
Consent and Waiver.
Participant’s Name Printed:
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Date: