Houston Helpers
This form is intended to be for one person/family at a time. If you have more than one referral, please complete the form separately for each one.
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Who is filling out this survey? (Name) *
Your Phone Number *
Your Email Address *
How do we know each other? (This helps the people organizing things)
Do you live in Houston, and/or do you know someone who lives in Houston and would like to help? *
Name of the person you are referring us to.
What is the contact information of the person you are referring (Name, phone number, email address)?
How are you or your referral interested in helping?
If yes to housing, how many miles/minutes are you/your referral from downtown MD Anderson?
If yes to housing, can you describe what the setup is (please be as detailed as possible)? (ex: 1 bedroom, guest bathroom, can put kids on the couch)
If yes to housing, how long are you/your referral comfortable having us stay?
If you chose transportation, meals, or visiting us, what do you feel comfortable with?
Other thoughts, notes, etc.
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