HOSTS for HOSPITALS Guest Liability Release & Demographic Form

Part A: Liability Release Form

This form must be signed and submitted online by an adult member of the Guest party within 24 hours prior to when the Guests will first be arriving at the the Host-home.

Patient Name:

First Name *

Last Name *

Philadelphia-area hospital where patient is being seen: *

In response to the lodging application the undersigned, upon receipt of this document by HOSTS for HOSPITALS (HfH), will be been put in contact by HfH with the Host(s) which has/have agreed to furnish the Guest(s) accommodations. The undersigned is one of the Guests who will be receiving such lodging. The undersigned moreover recognizes that any modest reimbursement paid to the Host(s) and any donations to HfH which the undersigned may have made for furnishing the said accommodations represent only a small portion of the value thereof.

Accordingly, as an inducement to the Host(s) to make the placement facilities of HfH available, and to furnish the said guest accommodations to the undersigned for himself/herself/themselves, and on behalf of any minor children of the undersigned who will share the accommodations, the undersigned hereby voluntarily assume(s) all risks of accident, injury to the person or damage to property arising out of or in connection with his/her/ their use and occupancy of the said accommodations or the furnishings thereof, including without limitation, any such injury or damage occurring for any reason in or upon the real estate owned or occupied by the Hosts(s) at the aforesaid address or upon any street, sidewalk, driveway or other property adjacent to or giving access thereto, or attributable in whole or in part to the condition thereof, the actions or omissions of the Host(s) or any member of the Host’s/s' family, or any other guest, servant or agent of the Host(s), or the condition, operation or action of any personal property, fixtures, persons or animals therein.

And the undersigned for himself/ herself/themselves, and on behalf of the said minors, hereby remise(s) and release(s) and forever discharge(s) each of the persons, corporations and unincorporated bodies to whom this release is addressed and each member and every director or similar fiduciary thereof and their respective officers, agents and employees of and from any and all demands, actions, causes of action, suits, claims and liabilities whatsoever arising out of or in connection with any event, occurrence or incident set forth in the preceding paragraph whether caused by the negligence of any of the parties so released or otherwise.

And the undersigned hereby further agree(s) to indemnify, hold harmless and defend any and all of the said actions against any and all such claims or liabilities asserted against them or any of them by third persons by reasons of any acts or omissions of the undersigned or his or her minor children or animals occurring during the period that the said accommodations are being furnished.

1. Have you (or any guests accompanying you) tested positive for COVID (via lab or home test) in the last 10 days? *

2. Have you (or any guests accompanying you) been in close contact with anyone that has tested positive for COVID in the last 10 days? *

3. Do you (or any guests accompanying you) currently have any flu or cold symptoms with or without fever such as cough, sore throat, fatigue, loss of taste or smell? *

If the Guests will be staying at a Host-home when the Hosts will be living there as well, the undersigned further represents that: *

a member of the Guest party has discussed with a HOSTS for HOSPITALS representative requirements pertaining to lodging at a Host-home.

WITNESS THE EXECUTION HEREOF as a document under the seal at Gladwyne, Pennsylvania this * +

Guest First Name: *

Guest Last Name: *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip Code/Postal Code *

Phone Number *

Country *

Email Address *

Guest Signature: *

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Part A: Demographic Form

We fund our operations in large part through grants from foundations.

Foundations in turn request that we provide statistics documenting to whom we provide lodging assistance.

We therefore need for you to answer these questions below--note that we will not use your names as we compile these statistics.

Thank you so much for helping us so that we may help other patient-families in the future!

Age of the patient for whom you have come into town: *

Patient gender *

What is your household’s annual income? *

Thank you for your participation.