Short-Term Housing Application

Email *

Mobile Number *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Patient Gender *

Male Female

Drivers License # and State: *

Texas Medical Center (TMC) Oncologist Name *

First

Last

Texas Medical Center (TMC) Phone Number *

Treatment Center / Hospital *

Cancer type and please list any clinical trials *

Choose which is applicable *

Inpatient Outpatient

Does patient use assistance *

Yes No

Is everyone staying in the residence able to navigate stairs? *

Yes No

Does patient use a service animal *

Yes No

Are you a US citizen or have permanent legal residency in the US? *

Yes No

Do you understand english *

Yes No

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

Specific date service is needed: start date and end date ( Estimated if unknown) *

Who will need to be housed? Please list name of children & adults *

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

Religion (not required to answer) *

How did you hear about A Shelter for Cancer Families? *

I agree that I am applying through A Shelter for Cancer Families (ASCF), for guest accommodations to be furnished to me and if applicable to my minor child/ren at our residences located at 4115 Drake in Houston, Texas during the hospitalization and/or treatment/diagnostic testing for the patient named below. *

Accept Decline

Please enter patient name *

First

Last

Please read, acknowledge your understanding of, and agreement to, the conditions of your application with ASCF for a personal license to use the ASCF residence as temporary housing. By accepting, you are acknowledging that you understand and agree to all of the ASCF Housing Policy and Guest Liability Release statements on this application. *

Accept Decline

I have been provided information on the property and short-term housing program and ASCF has agreed to furnish such guest accommodations. I recognize that any donation(s) to ASCF, which I may have made, represent only a small portion of the value of accommodations offered *

Accept Decline

The primary applicant for himself, herself or themselves, and on behalf of the said minors, hereby remises and releases and forever discharges ASCF, its Directors, Staff and/or Volunteers to whom this release is addressed. *

Accept Decline

The primary applicant releases each member and every director or similar fiduciary thereof and their respective officers, agents and/or employees from any and all demands, actions, causes of actions, suits, claims and/or 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. *

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The primary applicant hereby further agrees to indemnify, hold harmless and defend any and all of the said addresses 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 primary applicant or his or her minor children or animals occurring during the period that the said accommodations are being furnished. *

Accept Decline

Families are required to comply with all laws set forth by our local, state and federal government. Each family member housed by ASCF must also agree to adhere to ASCF’s rules as well as any specified rules by the owners of our apartment property. Please make sure to obtain the most recent copy of the property's community policies upon arrival. *

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Unfortunately, at this time, our program is unable to accommodate families who have neither legal United States Citizenship nor permanent legal residency in the United States. *

Accept Decline

ASCF serves out-of-town families and/or individuals seeking cancer treatment, following-up and/or second opinion in the Texas Medical Center on a first-come, first-served basis. Before a family may be considered, a complete application must be received by ASCF. Housing is intended for those cancer families seeking SHORT-TERM, TEMPORARY accommodations in the medical center. *

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ASCF cannot accommodate individuals who may be traveling unaccompanied who are unable to provide self-care. *

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Guests must have a back-up plan. All services depend on the availability of short-term housing accommodations. *

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All Patients, Caregivers, Family Members and Guests 18 years old and over (who plan to stay overnight in ASCF housing accommodations) must complete the ASCF online background check at least 4 full business days and no sooner than 1 week in advance of the anticipated date of arrival to provide adequate time for processing *

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Each stay requires the completion of a new Application, Background Check and approval from ASCF. *

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Residences are provided free of charge to cancer patients and their families on a first-come, first-served basis, on a temporary basis only (less than 8 weeks per visit) *

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If there is a change in travel plans, it is the Guest’s responsibility to notify ASCF as soon as possible prior to scheduled arrival and/or departure. *

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All guests must be able to provide proof that they have a permanent home to which they will return after their temporary stay. Guests who abuse the 8-week maximum stay, will be asked to pay $150/per day for every day they stay beyond their agreed check-out date. *

Accept Decline

ASCF recognizes that treatment for cancer can be unpredictable and you might need to remain in the area for treatment. Every effort will be made by ASCF to accommodate such circumstances when absolutely necessary, however, no guarantees can be provided since we are attempting to help as many people as possible and may have made a commitment to other patients on our schedule. *

Accept Decline

It is the responsibility of the Guest to notify ASCF no less than 24 hours before any absence during an approved stay. If the Guest is absent for more than 4 days in a seven-day period the reservation will be cancelled and Guest will need to re-apply for a new stay period, unless ASCF has previously approved a separation in the stay. *

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The primary applicant must provide a security deposit of $250 one week prior to anticipated date of check-in. An inventory must be completed by the guest upon arrival (within 24 hours of check-in) and submitted to ASCF. A general inventory will also be conducted by housekeeping upon check-out/departure. Any and all damage to the residence and/or its contents will be the sole responsibility of the primary applicant. Damaged property and/or missing or damaged items (including keys) will result in a forfeiture of the primary applicant's security deposit. The deposit will be refunded upon final cleaning of the residence (after check-out) provided that the residence is in good repair and condition. Should there be damages or loss, the primary applicant will be notified of charges incurred which will be deducted from the applicant’s security deposit. Primary applicants are responsible and will be held financially liable for the actions and/or behavior of their guests while on ASCF premises. *

Accept Decline

No Smoking, No Tobacco or Pets - It is important to provide a clean, allergen-free environment for patients. The residences are subject to a strict no smoking, no tobacco and no pets (of any kind) policy. Only service dogs are excluded from this policy *

Accept Decline

All guests must notify ASCF at [email protected] in advance of departure. Please provide as much notice as possible so that we may plan in advance to have the unit reset and refreshed for the next family. Adherence to this procedure allows us to serve as many families as possible. *

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Upon check-out, all keys must be returned to ASCF and this must be done during regular business hours. The security deposit will not be refunded if all keys are not returned. *

Accept Decline

ASCF is not responsible for lost, left-behind or stolen items, or for injuries suffered or for accidents on the premises. *

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Every effort should be made not to waste electricity. Please turn off lights when you leave each room and leave doors and windows closed so as to keep residence cool in the summer and warm in the winter. This also prevents bugs from entering the residence. Electricity usage charges over $150/month may result in a charge to the primary housing applicant. *

Accept Decline

Guest/s or family members who fail to adhere to the ASCF Housing Policy & Guest Liability Releases will have their license terminated and are subject to immediate dismissal from the housing provided and may become ineligible for future housing assistance. A guest may have his/her license terminated and be asked to leave the residence provided if the guest, caregiver, a family member, friend or other invitee fails to adhere to the Housing Policy and Guest Liability Releases. *

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Any person who, in the sole opinion of ASCF has been, or is likely in the future to be disruptive or harmful to other Guests, the operation of the residence, or the environment must vacate the Premises immediately upon the request of ASCF and failure to do so will result in such person/s being guilty of trespass. *

Accept Decline

I understand that I am a Guest of the ASCF residence under a personal license and will vacate the premises immediately if asked to do so by the ASCF representative. If I fail to leave the residence within three (3) days from the date requested, I agree that I will be responsible and will pay a fee of $150/day for each day thereafter until the residence if fully vacated. I understand that the $150/day fee constitutes liquidated damages for my failure to leave and agree that it is a reasonable amount to compensate ASCF for the damages it will suffer as a result of my failure to vacate when requested. *

Accept Decline

I understand that my personal information will be transmitted and stored securely via Flipcause (a third party online engagement platform used by non-profit organizations to ensure information is collected and transmitted securely). *

Accept Decline

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

I hereby grant A Shelter for Cancer Families (ASCF) permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. *

Accept Decline

Short-Term Housing Application

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