Patient Information:

* Patient Name ( First and Last )

* Patient Date of Birth (MM/DD/YYYY)

Patient Gender

Diagnosis

Stay Information:

* Check In Date

Anticipated Check Out Date (if known)

Insurance Information:

Medicaid Branch

Medicaid Id (if no medicaid, type N/A)

Do you have private insurance?

If yes, list private insurance information:

Guardian Information:

* Guardian/Caregiver Name (First and Last)

Guardian/Caregiver Driver's License Number:

* Date of Birth (MM/DD/YYYY)

Relationship to patient

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

Zip

Primary Phone Number

* Email

Car Make/Model/Description

Car License State

License Plate#

Second Guardian/Caregiver Name (First and Last)

Second Guardian/Caregiver Driver's License Number:

Date of Birth (MM/DD/YYYY)

Relationship to patient

Primary Phone Number

Email

Additional Guest Information:

All family members 18 years of age or older applying to stay at Hogs House must successfully clear a background screening for criminal sexual offenses to be accepted as an overnight guest. Please complete the following information for all adult family members requesting a reservation (Rooms hold up to three adult family members.)

Click the 'Add Another Guest' Link below to add additional guests and patients.

Guest 1 Driver's License Number:

Guest 2 Driver's License Number:

Guest 3 Driver's License Number:

Additional Information:

What is your annual household income?

Do you need a handicap accessible room?

Are there any other hardships you would like us to know about like issues with accessing housing,transportation,food etc?

GUEST RULES AND AGREEMENT

Checking each of the House Rules listed below indicates your acknowledgement of receipt of this information and your family's agreement to uphold these rules throughout your stay at Hogs House.

* Hogs House has the right to limit the number of registered guests per room. Registered guests are limited to immediate family members or primary caregivers.

* All registered guests and visitors must wear the appropriate identification badges (issued upon arrival).

* Appropriate dress must be maintained at all times. Guest must be fully clothed with shoes or slippers at all times.

* Children under 18 must be accompanied at all times and never left in the house without supervision.

* *Food and drink (with the exception of water or baby formula) are not allowed in private rooms. 

* Guests are required to clean up in all common areas after use including the public dining area and family kitchen. 

* Loud or disruptive behavior is not allowed at any time. Quiet hours are from 10:00 PM to 9:00 AM.

* Guest are responsible for keeping their room clean. A dumpster is located on the xxxx side of the building for your trash.

* Callers who ask for a registered guest will not be given any information. Visitors who come to see a registered guest must be met in the lobby.   

* No pets, except service animals, are allowed on Hogs House property.

* Smoking, vaping or the use of any tobacco product is not permitted anywhere in the Hogs House.

* Hogs House conducts random room checks at least once a week. Management does reserve the right to conduct more than one room check a week at the discretion of the leadership team.

* In the event that the room will be unoccupied for 24 hours, guests must properly check-out of the room and ask to be put back on the waiting list for the date of their return.   

* Hogs House will not be responsible or liable for any loss of or damage to personal property or for any personal injuries, illnesses, or deaths, even in the event of negligence.   

* Hogs House conducts a background check on all guests and visitors the age of 18 or over. Results of the background check may disqualify an individual from staying in the house or visiting in the public common areas.

* Child abuse, domestic violence, or obscene language and gestures will not be tolerated.

* No weapons, alcohol, or illegal drugs will be allowed to be used, consumed, or stored anywhere on the Hogs House property. "Pursuant to Section 30.06, Penal Code (trespass by holder of license to carry a concealed handgun), a person licensed under Subchapter H, Chapter 411, Government Code (concealed handgun law), may not enter this property with a concealed handgun.

* People exposed to or having contagious illnesses may be required to vacate the House. Guests who have been diagnosed with a contagious illness must notify the office immediately.

* Lodging at the Hogs for the Cause Family Support Home is a privilege and not a right. All guests are expected to abide by the rules of the Hogs House AND to act responsibly in all instances, which may or may not be outlined in this document. Failure to do so may result in being required to immediately vacate the House based on the discretion of management.

* I have read and understand the guest rules and agree to abide by them.

* I also agree to be responsible for my family and visitors.

* I swear that the information provided on this form is true and correct to the best of my knowledge.

* I further authorize Hog for the Cause Family Support Home at Our Lady of the Lake Childrens Hospital to produce and make use of any photographs or videos of the patient, my family, and myself for the purpose of publicizing the services and work of the Hogs House or medical institution, without any compensation to us or retention of any ownership or other rights. 

Damage to Room

Damage to rooms, fixtures, furnishings, and equipment including the removal of electronic equipment including the removal of electronic equipment, towels, artwork, etc. will result in the loss of any future lodging privileges and may result in fees to cover the cost of any damages or missing items. You are liable for any damage howsoever caused (whether by deliberate, negligent or reckless act) to the room(s), premises, or property caused by you of any person in your party whether or not actually staying overnight at Hogs House. 

Damage or Tampering with Fire Detection Systems/Fire-Fighting Equipment

The Hogs House staff reserves the right to take action against any guest or visitor found to have tampered or interfered with any detection equipment throughout the building, including detector heads in public areas, guest rooms, break glass points, and fire extinguishers.  Guests or visitors found to have tampered with any fire detection or firefighting equipment will have to vacate the premises immediately and will lose any future lodging accommodations. Depending on the severity of the guest actions, law enforcement may become involved at hospital discretion. Should evidence of any tampering come to light after the guest has departed, we reserve the right to refuse or deny any future lodging accommodations.

Missing Belongings

In addition, I agree that Hogs House is not responsible for any belongings that are brought into the premises and agree to release Hogs House and its officers, directors, employees, and agents from any claims arising from missing or stolen belongings.

 

Each guest staying at Hogs House must consent to the above by signing in the Electronic Signature box below.

Electronic Signature 1:

Electronic Signature 2:

Electronic Signature 3: