Application for Family, Guest and Caregiver

A SHELTER FOR CANCER FAMILIES

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Application for Family, Guest AND/OR Caregiver

* Indicates required field

Name *

First

Last

Email *

Mobile Number *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Gender *

Male Female

Drivers License # and State: *

Name of patient/primary applicant you will be staying with *

First

Last

Do you understand English? *

Yes No

If you answered no to above, what is your primary language? *

Have any infectious diseases: *

Yes No

Been convicted of violent crime, crime against a child, theft or illegal drugs *

Yes No

Have a civil or protective order against you or are you currently on probation or parole *

Yes No

Required to register on the state or national sex offender registry *

Yes No

In conjunction with this application, I agree and consent to a background check being performed on me by ASCF or its agent which may include all or some of the following: verification of information provided, confirmation of a cleared criminal background status; and obtaining such additional background information as ASCF deems necessary. To the best of my knowledge all information obtained in this application is accurate. *

Accept Decline

Submit

4115 Drake Street, Suite #4, Houston, Texas 77005
713-497-5365
info@cancerfamilies.org

ASCF is a registered 501(c)(3) non-profit organization. Tax ID:76-0674858.
Contributions to ASCF are tax deductible to the extent permitted by law.

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About Us
HOW TO HELP
- Donate
- Volunteer
FOR FAMILIES
Events