General Information

*Required fields

*Hospital
 

*Returning Family: No     Yes

*Patient's First Name


*Patient's Last Name


*Patient's Date of Birth
Month Day Year

*Patient's Age:

*Patient's Gender: Male     Female

*Accompanying Parents or Guardians


*Home Address


*City


*State


County


*Zip Code


*Country


*Home Phone
e.g. 626-585-1588

*Mobile Phone
e.g. 626-585-1588

*Email



Medical Information


*Diagnosis


Comments/Specifics


*Child is Currently

Referred By

e.g. Social Workers name, Doctor's name, etc.

Referrer Title


Referrer Phone


*Wheelchair Need?   No     Yes     Other:


Payment Information


*Payment Type


Payment Comments



Request Details


*Arrival Date
Month Day Year

*Estimated Departure
Month Day Year

*Please enter the total number of individuals who will be staying at the House.

Adults


Children
0 (zero) for none


 


Important Information for Families:
  • Check In Hours: 9:00am - 9:00pm (Check Out is 12:00pm)
  • Room request does not guarantee a reservation. Call for confirmation. 626-204-0401 or 626-585-1588 x0
  • A $15 fee per night is requested plus a $10 cash key deposit for each room key needed required
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