Guest Lodging Application

LODGING APPLICATION

Welcome to the HOSTS for HOSPITALS Lodging Application. Please fill in as much information as you know. As an added convenience, you can create an account (click the button "Create an account" below) so that you can come back and update any of the information. If you have any questions, please reach out to us at 484-380-2999 or lodging@hostsforthospitals.org. -Thank you

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Sections of this application:

A. Person filling out this application

B. Person referring patient-family to HOSTS for HOSPITALS

C. Patient Information

D. For persons needing lodging

E. For ALL of the guests, (including the patient if patient will be a guest)

F. For each guest over the age of 18

A. Person filling out this application

First Name *

Last Name *

Street Address

Address Line 2

City

State/Province/Region

Zip/Postal Code

Phone Number *

Country

Email Address *

Relation to Patient *

How did you hear about HOSTS for HOSPITALS? *

B. Person referring patient-family to HOSTS for HOSPITALS

First Name

Last Name

Phone Number

Email Address

Institution

Department

Position

C. Patient Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Phone Number *

Email Address *

Birthday (Please double check the year) * +

Hospital being treated at in Philadelphia *

Medical Department *

Lead Physician (if known)

Condition receiving treatment for *

Will the patient be a guest? *

Expected start date for lodging +

Expected end date for lodging +

D. For persons needing lodging

Besides Patient (if lodging), how many guests at most will need lodging at one time? *

If other, please explain. *

Guest 1

First Name *

Last Name *

Address Match *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Birthday (Please double check the year) * +

Relation to Patient *

Is the expected start date known? *

If 'Yes', what is the expected start date? * +

Is the expected end date known? *

If 'Yes', what is the expected end date? * +

Guest 2

First Name *

Last Name *

Address Match *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Birthday (Please double check the year) * +

Relation to Patient *

Is the expected start date known? *

If 'Yes', what is the expected start date? * +

Is the expected end date known? *

If 'Yes', what is the expected end date? * +

Guest 3

First Name *

Last Name *

Address Match *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Birthday (Please double check the year) * +

Relation to Patient *

Is the expected start date known? *

If 'Yes', what is the expected start date? * +

Is the expected end date known? *

If 'Yes', what is the expected end date? * +

Guest 4

First Name *

Last Name *

Address Match *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Birthday (Please double check the year) * +

Relation to Patient *

Is the expected start date known? *

If 'Yes', what is the expected start date? * +

Is the expected end date known? *

If 'Yes', what is the expected end date? * +

Guest 5

First Name *

Last Name *

Address Match *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Birthday (Please double check the year) * +

Relation to Patient *

Is the expected start date known? *

If 'Yes', what is the expected start date? * +

Is the expected end date known? *

If 'Yes', what is the expected end date? * +

Guest 6

First Name *

Last Name *

Address Match *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Birthday (Please double check the year) * +

Relation to Patient *

Is the expected start date known? *

If 'Yes', what is the expected start date? * +

Is the expected end date known? *

If 'Yes', what is the expected end date? * +

E. For ALL of the guests, (including the patient if patient will be a guest)

How many beds are needed? *

How many rooms are needed? *

We know guests always prefer to have their own private bathroom. However, if need be, are you able to take turns in a bathroom with a member of the host-family*? *

If not, Why? *

Do any of your guests smoke? *

If 'Yes', who in your party smokes? *

For the heaviest smoker, about how cigarettes are smoked each day? *

Will guests be at the home a lot during the day? *

If Yes, Please explain *

Do you plan on having a car? *

If need be, will you be able to rent a car or take a service such as Uber? *

Do any of the guests need wheelchair access? *

Will the guests wish to use the kitchen? *

Do any of the guests have limitations going up and down stairs? *

If ‘Yes’, what is the maximum of stairs that can be managed? *

Many of our homes include very nice pets.

Do any of the guests have reactions to cats? *

Fine with cats

Allergic

Afraid

Do any of the guests have reactions to dogs? *

Fine with dogs

Allergic

Afraid

Do the guests speak English? *

If not, what language(s) do the guests speak? *

Please discuss the patients condition as it pertains to staying at a host-home, even though if at this time the patient will not be a guest.

Are there any other guest medical conditions that HfH should be made aware of? *

F. For each guest over the age of 18,

we require the name and phone number of a healthcare provider whom we may call to receive a character reference for that guest.

If you are located outside the U.S., we would require that your character reference person fax us or attach in an email your reference written upon the letterhead of that person's medical office. Our fax number is 215-472-3803.

Anyone who is in the position of providing healthcare to that guest--such as the guest's primary doctor, dentist or eye doctor--may serve as the reference provider.

When we call the character reference, the basic question which we will ask is: based upon your experience in knowing the applicant from the office visits, could you recommend this person as someone you think would be considerate when staying in another person's home?

Please provide the guest name, reference name and contact information for each guest.