2025 Annual Picnic-Late Registration

WE ADMIT 7 DAYS A WEEK
Same day admissions possible - Most insurance accepted

800-543-9905

Submit A Confidential Inquiry

2025 Annual Picnic:

Sunday, September 14, 2025
Noon-3:00pm

Serenity Lane's Coburg Campus
1 Serenity Lane
Coburg, OR 97408
VIEW MAP

For more info:

Abby Schmidt
Serenity Lane Alumni Manager
aschmidt@serenitylane.org
541-606-4446

Registration:

*If you are the loved one of someone currently in residential treatment with us, you do NOT need to register as long as you are on their visitation list. Please check with your loved one if you are unsure.

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Date

Name*

First Last

Email*

Phone

I am:*

Sobriety Date

Name of Alumni or Patient you are associated with

How many guests are you bringing (not including you)?*

*Maximum group of 4. If you need help paying or would like to bring a larger group, please contact Stephanie or Abby.

Please enter a number from 0 to 3.

GUEST #1:

Name of Guest #1

First Last

Age

Adult (18+)

Minor (under 18)

Email Address (adult guests only)

GUEST #2:

Name of Guest #2

First Last

Age

Adult (18+)

Minor (under 18)

Email Address (adult guests only)

GUEST #3:

Name of Guest #3

First Last

Age

Adult (18+)

Minor (under 18)

Email Address (adult guests only)

Confidentiality Statement*

DO NOT VIOLATE OUR PATIENT'S CONFIDENTIALITY

Those who have sought treatment for Substance Use Disorders (SUDs) have their confidentiality protected by 42 CFR, Part 2. In some cases these regulations are more stringent than HIPAA.

Confidentiality in this field is protected in two ways:
1. All information identifying a person as having a Substance Use Disorder is confidential and may not be released without consent from the patient.
2. All Protected Health Information (PHI), including demographic data that is created by Serenity Lane and relates to the patient’s medical or mental health, the services provided, and payment provided falls under the protection of HIPAA and may not be released without consent by the patient.

Federal regulations (42 CRF Part 2) prohibits anyone from disclosing the identity of our patients without their written permission. Violations of confidentiality may be punishable under the law. If you see anyone you know or meet someone on these premises, you are required by law not to disclose the information to anyone. This regulation applies to everyone, no exceptions.

I have read the confidentiality statement and agree to respect patient privacy.

*If cost is a barrier, please contact Abby ASchmidt@serenitylane.org or Stephanie SAxley-Cordial@serenitylane.org for assistance.

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800-543-9905