Home   History   FAQ   Applications   Photo Gallery   Donations   Fundraising   Links   News   Contact   Volunteer   National Program HOSTS for HOSPITALS has provided free lodging at our host-homes for hundreds of families which have come from around the world to receive care at a Philadelphia area medical institution and would be happy to arrange lodging for your family as well. Below is the information we need so as to be able to offer you lodging. All information received will be treated as confidential. Once we receive this information, we then will be back in touch with you within two business days. If lodging is needed immediately, please call our office directly rather than applying on-line: 610-660-6667. If you find that you are unable to send this application on-line, please contact our office by the phone number above or by email: hfhospitals@aol.com. (* = required field) A) How did you learn about HOSTS for HOSPITALS? B) Information about the patient First Name: * Last Name: * Birth Date: * Street Address: * Either a complete U.S. address or a foreign address is required. City: * State: * Zip Code: * Address (for non-US residents): Contact Phone Numbers: * At least one number is required. Home Phone: Mobile Phone: Work Phone: Other Contact Information: Email Address: Fax Number: Institution being treated at in Philadelphia: * Department (if a hospital): Lead Physician (if known): Condition being treated for: * Will the patient need lodging?: * Yes No Expected starting date for lodging: * Not Sure Expected ending date for lodging: * Not Sure C) Individuals requiring lodging Please supply information for each individual who will need lodging. To add someone click the "Add a new individual" link below. (Note: Clicking this link will launch a pop-up page to allow you to add individuals. You may need to disable your browser pop-up blocker for it to function properly.) [Add a new individual] Already added people: No one has been added yet. D) Addition information about all guests    (including the patient if they are to be a guest) How many beds are preferred? *   How many rooms are preferred? *   Do any of the guests need a private bathroom? No Yes Do any of the guests smoke? If so, would they agree to only smoke outside? No Yes No Yes Will guests be at the host home a lot during the day? * Will the guest(s) have a car available? No Yes Do any of the guests need wheelchair access? No Yes Will the guests wish to use the kitchen? No Yes Do any guests have limitations going up and down stairs? * Are any guests allergic to cats? Are any guests allergic to dogs? No Yes No Yes Are any guests afraid of cats? Are any guests afraid of dogs? No Yes No Yes Do any of the guests not speak English? * If so, whom? If the patient is to be a guest, please discuss the patient's condition as it pertains to staying at the host-home: Are there any other guest medical conditions or needs of any of the guests we should be aware of? E) Additional Information Please provided the following information if it is now available: Individual Reference Name: Reference Phone Number: Patient: * * We only need this information if the individual is the age of 18 or above. For each guest over the age of 18 years old, normally we require the name and phone number of a healthcare provider whom we may call to receive a character reference for that guest. For guests who are located outside of the United States, we require that the character reference person fax us the reference written upon the letterhead of that person's medical office. Anyone who is in the position of providing healthcare to the guest-such as the guest's primary doctor, dentist or eye doctor-may serve as the reference provider. When we are in contact with the reference provider, the basic question which we will ask is: based upon your experience in knowing the applicant from the office visits, could you recommend this person as someone you think would be considerate when staying in another person's home? When you have completed this form click here: