For completion by Guest

I understand that Clayton’s House is not a staffed facility and does not provide aides or other medical or physical supports. I am aware that it is a place of respite, a shared living space, and that during my stay, I may be the only guest occupying the premises. I agree that I am responsible for my own safety, health, and well-being during my stay.

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 understand that submission of a completed referral form from a clinical care team member who is directly involved in the treatment of the person with the cancer impact, is a prerequisite to a stay at Clayton’s House. By signing below, I represent and attest that:

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 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.

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 Rules, 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 Rules.  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.