Apply to Stay at Anna's Homes

Apply to Stay at Anna's Homes
Eligibility

A parent/legal guardian/caretaker who is staying in Anna’s Homes must meet the following criteria:

• Have a child in treatment at Sacred Heart Children’s Hospital for cancer
• Be 18 years of age or older. A parent under 18 must be accompanied by a parent, legal guardian, or another adult over 18
• Live at least 45 miles away, have your own transportation, and maintain a permanent physical address for one year or more
• Pass a criminal background check
• For children in state custodial care, the applicant must be a foster or future adoptive parent

This form is only for screening and does not guarentee admittance to Anna's Homes. Once submitted, the Anna Schindler Foundation will contact you to have you fill out a full application.
Who is completing this registration?
Have you stayed with us before?
Primary Language
Who Are You Caring For?

Patient Information
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Gender
Patient's Medical Insurance
Medicaid ID (if applicable)
Medicaid Branch
If patient has private insurance, please add the provider and # if possible.
Have you check to see if your insurance has a lodging benefit?
Reason for Stay
Additional diagnosis information (i.e. type of cancer, etc.)
Patient is being treated at:
Assigned Social Worker
Who will be staying at Anna's Homes?

All guests over the age of 18 must have a background check.
Parent/Caregiver Name

First NameLast Name
Relationship to patient
Parent/Caregiver Name

First NameLast Name
Relationship to patient
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
I agree to receive texts at these numbers

YesNo
Email
example@example.com
Email - secondary
example@example.com
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Total number in the immediate family
Additional Guest over 18

First NameLast Name
Relationship to patient
Date of Birth

MonthDayYear
Date
Additional Guests / Family Members*
When do need housing?

MonthDayYear
Check-in Date
Anticipated Check Out Date

MonthDayYear
Date
Special accommodations or other information we should know? (ex: hearing impaired, ADA accessibility required, etc.)
Conduct Expectations of Families, Guests, and Visitors

• No guest may have any criminal felony/misdemeanor convictions. This includes, but is not limited to: violent crime, domestic violence, child abuse, sexual offense, illegal drug activity, burglary, theft, hate crimes, or internet crimes. Public records will be reviewed for the last 5 years and background checks conducted.
• Anna’s Homes will not house anyone with a pending case involving the above offenses.
• Guests must not have any known contagious illness at the time of screening (e.g., chicken pox, lice, measles, mumps, whooping cough, or influenza).

• Absolutely no smoking or pets of any kind is allowed inside Anna’s Homes. Violation is grounds for immediate eviction. Homes must remain free of any smells or allergens that cause discomfort to the patient and their family. No smoking within 20 feet of any entrance.
Should be Empty:

Apply to Stay at Anna's Homes

Who Are You Caring For?

Who will be staying at Anna's Homes?