Dempsey Center›Registration Forms›Clayton’s House Guest Application

Clayton’s House Guest Application and Waiver Form

For completion by Guest

Submission of this completed Form is a pre-requisite to a Guest’s stay at Clayton’s House.

Identification of Guest

Name:(Required)
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Home Address:(Required)
Name of Care Partner:(Required)
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I agree to submit a valid photo identification upon check-in(Required)

Acknowledgement of the Care Partner Role

I acknowledge that Clayton’s House requires a Care Partner to be designated by me, and to always accompany me while I am on the Clayton’s House premises. I understand that Clayton’s House does not provide aides or other medical or physical supports. I understand that the Care Partner must be at least 18 years of age, submit a separate Care Partner form, and be: 
  • Knowledgeable of my cancer diagnosis and condition and physical limitations and needs to be able to support my stay in Clayton’s House;
  • Capable of providing physical support for my daily living, including with respect to ambulating, hygiene, meal preparation, transportation, and housekeeping;
  • Able to assist with administration of any prescribed medications that I may require during the stay;
  • Able to recognize and respond appropriately to an emergency, including being able to contact 911 in the event of an emergency.

Eligibility

I understand that submission of a completed referral form from a clinical care team member who is directly involved in my cancer treatment, is a prerequisite to a stay at Clayton’s House. By signing below, I represent and attest that:
I meet the medical and physical criteria for a stay at Clayton’s House. Specifically, I am:(Required)
  • I have or shall have submitted an executed referral form from a clinical team member directly involved in my cancer treatment.
  • The period of time I seek to stay at Clayton’s House shall be when cancer treatments are scheduled and received, plus an additional 24 hours following conclusion of the treatment.

Attestation Regarding Other Standards and Rules

I understand that each Guest at Clayton’s House is required to meet the following standards. By signing below, I am certifying that I meet these standards and will abide by all Clayton’s House Terms of Stay and requirements.
  • I have read and understand the Clayton’s House Terms of Stay.
  • I agree to abide by the Clayton’s House Terms of Stay.

Accommodations

Are you capable of being assigned to a room on the 2nd or 3rd floor without elevator access?(Required)
Do you and the Care Partner require a room with two beds?(Required)
Are you aware that there is limited parking on site?(Required)

Waiver and Release

The approval by Clayton’s House of my stay in the Clayton’s House is conditioned upon my agreement to abide by all applicable laws and to follow Clayton’s House Terms of Stay while on the premises. Failure to comply with the laws and Terms, particularly those that seek to protect the health, safety and wellness of all patrons, may result in refusal of admission or expulsion. Further, I agree to release and waive any and all claims for losses or injury arising from my failure or the failure of my Care Partner to abide by any laws or Clayton’s House Terms of Stay. In addition, I agree to release and waive any and claims arising out of or related to the transmission or contracting of any communicable disease, including but not limited to COVID-19.

Signature

I agree that my electronic signature is the legal equivalent of a manual signature. I acknowledge that this document contains a WAIVER and RELEASE of claims.(Required)
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