Daisy's Place Guest Application 

Text or Call when form is completed. 256-629-6729

To qualify:

Guests must be immediate family members or designated caregivers of a hospitalized patient receiving care in the Shoals and must have a verifiable permanent residence outside of Lauderdale and Colbert County, Alabama.

Guests/caretakers should be actively involved in visiting their loved one, for the majority of the day. 

Your eligibility to be our guest requires you to be an active caretaker of a loved one in a Shoals area approved medical facility.

Each person must fill out an application and will be contacted within 24 to 48 hours. Availability not guaranteed.

Thank you
Email *
Today's Date *
Your Full Name *
Your Phone Number *
Your Email *
Name of loved one in the hospital? *
What Hospital are they in and what is their room number? *
Will you be the only one taking care of your loved one?
If not who else will be taking care them?
(They will also need to fill out an application if wanting to be in the program and stay at Daisy's Place.)
 *
What is the reason for staying with us? *
Name and phone number of who referred you?  *
What is the name and phone number of your caseworker/social worker at the medical facility?
 *
How long do you think they might be there? *
 Please list at least one emergency contact person and their phone number? *
What dates are you needing to stay? *
Your Birthdate *
Your Address *
Your social security number (for background check purposes) *
Your driver's license number
Please email a copy of the front and back of your driver's license to info@daisys-place.org. It can be a picture taken by your phone.
 *
Make, model, and tag number of your car.
Example:
Honda Accord Tag# 123ABC
 *
Are you a U.S. Citizen? *
Do you have physical medical concerns or issues?
If so, please explain?
 *
Your Signature
By typing your name in this signature area you are verifying that all the information in this form is current and correct and that you are applying to stay with us while you take care of your loved one and that you agree to abide by all rules and local, state, and federal laws. You are also giving us permission to verify that your above named loved one is in an approved medical facility.
 *
Is there anything else that will help us get to know you better or to help you?
For questions call 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Daisy's Place.

Does this form look suspicious? Report

Google Forms