Application Form:

Application Form:
A. Information of Person Filling This Application:
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Relation to Patient:*
Parent, Sibling, Friend, Social Worker, etc...
Phone Number
Please enter a valid phone number.
How Did You Hear About Aashray?*

FriendHospital InformationSocial Worker/Hospital StaffReapplyingOtherDo no know
B. Patient Information:
Name*

First NameLast Name
Will the patient be a guest?*

Yes:No:
Please check this box confirming that you understand that Aashray Charities Inc. has the right to contact the patient's treating hospital regarding the patient's hospitalization status:*

I understand
C. Lodging Information:
Besides the patient (if lodging), how many guests will need to be accommodated at one time?*
(All patients under 18 must be accompanied by an adult)
How many beds are need?*
Maximum occupancy per room will be determined by the hotels policy
If known, from what date will you need lodging?*

MonthDayYear
Date
Do any guests smoke?*

YesNo
Do any guests have a pet?*

YesNo
Do any guests require wheelchair access?*

YesNo
Do the guests speak English?*

YesNo
D. Additional Information:
Please confirm that you understand you are responsible for any incidentals and charges outside of the cost of the lodgings.*

I understand
Please confirm that you understand that the hotel you are staying at will need your credit/debit card on file.*

I understand
If you are a guest at the Residence Inn Philadelphia Center City, please confirm your understanding that the hotel will place a temporary $60 hold per room on the card on file, which may remain for approximately 5 to 7 business days.*

I understand
Please confirm that you understand that you will be charged for any harm or damage to the hotel or its guests.*

I understand
Please confirm that you understand that there is currently a 5-day long limit to all stays, after which you can reapply for additional nights which will be provided by Aashray Charities Inc.'s discretion.*

I understand
Please confirm that you understand that accommodations are at no-cost, however, we have a suggested donation of twenty dollars per night, or whatever you can afford.*

I understand
Please provide a short explanation detailing why you need accommodations. (This information is for evaluating the efficacy of our program and will not affect your application status.)*
F. Beneficiary Feedback Request:
Your feedback helps us grow. If you click 'Yes,' we may reach out by email to invite you to complete a survey or share a testimonial.*

YesNo
E. Applicant Ackowledgement:
Please confirm that you have filled out the application truthfully and to the best of your ability.*

I confirm that I have completed this application truthfully and to the fullest extent of my understanding.

Application Form:

A. Information of Person Filling This Application:

B. Patient Information:

C. Lodging Information:

D. Additional Information:

F. Beneficiary Feedback Request:

E. Applicant Ackowledgement: