Application Form:
A. Information of Person Filling This Application:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
*
Email
*
example@example.com
Relation to Patient:
*
Parent, Relative, Sibling, Friend, etc...
Phone Number:
How Did You Hear About Aashray?
*
Friend
Hospital Information
Social Worker/Hospital Staff
Reapplying
Other
Do no know
B. Patient Information:
Name
*
First Name
Last 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?
*
-
Month
-
Day
Year
Date
Do any guests smoke?
*
Yes
No
Do any guests have a pet?
*
Yes
No
Do any guests require wheelchair access?
*
Yes
No
Do the guests speak English?
*
Yes
No
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 card on file.
*
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.
*
Yes
No
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.
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