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.Format: (000) 000-0000.
How Did You Hear About Aashray?
B. Patient Information:
Name

First NameLast Name
Will the patient be a guest?
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:
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?
Do any guests have a pet or service animal?
Do any guests require wheelchair access?
Do the guests speak English?
Will the guests require an early check-in and/or late check-out? (Please note that an early check-in and/or late check-out cannot always be accommodated.)
Please specify the time of your check-in. (Note that an early check-in cannot always be accommodated.)

Hour Minutes

AM/PM Option
Please specify the time of your check-out. (Note that a late check-out cannot always be accommodated.)

Hour Minutes

AM/PM Option
D. Additional Information:
Please confirm that you understand you are responsible for any incidentals and charges outside of the cost of the lodgings.
Please confirm that you understand that the hotel you are staying at will need your credit/debit card on file.
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.
Please confirm that you understand that you will be charged for any harm or damage to the hotel or its guests.
Please confirm that you understand that there is currently a 7-day long limit to all stays, after which you can reapply for additional nights which will be provided by Aashray Charities Inc.'s discretion.
Please confirm that you understand that parking and accommodations are provided at no cost. However, we suggest a donation of $20 per night, or whatever you are able to afford. If you are unable to donate, don't worry.
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.
E. Applicant Ackowledgement:
Please confirm that you have filled out the application truthfully and to the best of your ability.

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: