Online Guest Stay Request

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Guest Stay Request

1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

English spoken at Home

Request completed by

Staff

Social Worker

Social Worker Email (enter if blank/different)

Social Worker Phone (enter if blank/different)

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

Ethnicity

Diagnosis

Facility Treated At

* Inpatient - Hospitalized

COVID-19 Information

Vaccination Status

Vaccine Name

First Vaccination Date

Exemption Note

Vaccination Note

Does patient have private insurance?

Has patient stayed with us before?

Please enter the name of the Treating Doctor (optional)

Please specify any contact isolation precautions for the patient or anyone in your family that will be staying at the House

Has patient been exposed to any contagious diseases?

No

Yes

Add Another Patient

3. Guest Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

* Relationship to Patient

Contact Information

Email

Type of Email

Home Phone

* Mobile Phone

By providing your mobile number, please accept to get text messages from our organization. Message and data rates may apply. Visit our website for terms and privacy information. To stop texting, do not accept.

I accept to receive text messages on this number

Type of Address

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

Check this box to enter your vehicle information

COVID-19 Information

Vaccination Status

Vaccine Name

# Vaccinations

First Vaccination Date

Second Vaccination Date

Booster Vaccination Date

Exemption Note

Vaccination Note

VETERAN

Have you stayed with us before?

It is very important that you specify contact isolation precautions for the patient or anyone in your family that will be staying at the House.

Add Another Guest

4. Additional Information

VETERAN/FIRST RESPONDER STATUS: Please select from the following if you believe you are part of the classifications below (note: this is not a determining factor in your request to stay):

4b. Are there any special needs for your family? (wheelchair, etc.)

Notes regarding this request:

Acceptance

Your request will be processed. Do you want to continue?

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Your NPO
123 Nonprofit Lane
Give City, State 12345
info@yournpo.org

Merchant Test Info:
https://developer.authorize.net/hello_world/testing_guide.html

Test Card Brand	Number
American Express	370000000000002
Discover	6011000000000012
JCB	3088000000000017
Diners Club/ Carte Blanche	38000000000006
Visa	4007000000027
	4012888818888
	4111111111111111
Mastercard	5424000000000015
	2223000010309703
	2223000010309711

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Routing Numbers can be found at the Federal Reserve website.

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