PRIMARY GUEST DETAILS

Who is going to be the main person that we can coordinate with you during your stay?  

When do you need to stay with us? For how long?

PHYSICAL ADDRESS

Your current physical address

EMERGENCY CONTACT

Please list an emergency contact who will not be staying with you at The Our Promise House.

OTHER GUESTS

Who else will need to stay with you? Most rooms accommodate 2-3 adults comfortably. You may register two primary caregivers and up to two siblings of the patient receiving treatment.

TRANSPORTATION

VEHICLE DETAILS

BACKGROUND CHECK

Thank you for your inquiry to stay at The Our Promise House, Hot Springs, Arkansas.  We hope to assist your family during this challenging time.

The Our Promise House (“TOPH”), in order to undertake reasonable efforts to protect the safety of the guest families residing with us, now requires that each individual applicant (age 18 or older) who applies to stay at one of our Houses undergo a formal inquiry into their background (“background check”) to assess eligibility. This background check will include a private, multi-jurisdictional database of criminal records and a search of the National Sex Offender Public Registry for each individual age 18 or older.

All guest applicants are required to go through this process. You have the right to decline to have this background check performed. However, if you do decline the background check, we will have no choice but to deny your request for access to our facilities out of the need to take all reasonable efforts to protect the safety of our families. Please understand that TOPH solely will obtain a background check to assist in determining whether to grant you access to our facilities. TOPH is not obtaining a “consumer report” for any other purpose. TOPH will not be conducting a credit check. By accepting this authorization, you authorize us to obtain the background report described in it from a consumer reporting agency.

TOPH contracts a third party criminal background screening service in order to screen each individual guest applicant age 18 or older. Criminal background screening is required as part of the Guest application process for temporary residence at TOPH. TOPH will neither admit nor allow on premises any individual who provides false, incomplete, or misleading responses during the criminal background check process. Personal information required to complete background authorization forms is provided solely to the third-party screening service with consent from each individual applicant. The information obtained during the background check process will only be used by TOPH to determine whether to grant access to our facilities and will only be divulged on a “need to know” basis to those individuals or entities that it deems necessary to review that information. The information will not be disclosed for any other reason. All personal background information will be managed and stored by the contracted third-party service per said third-party’s standard policies and procedures.

TOPH reserves the right to refuse access to our facilities to any guest applicant who has a criminal history, including certain convictions, pending criminal charges or active probation, warrants or restraining orders. Anyone with a felony or misdemeanor conviction that may threaten the health, safety, welfare and ability of other individuals to peacefully enjoy the House is not permitted on TOPH premises. TOPH may also deny access to any individual with a pending criminal charge, active warrant or active restraining order, if the circumstances indicate such access may negatively impact the health, safety, welfare and ability of others to peacefully enjoy the House. If denial is based on circumstances other than a conviction, the individual may present additional information regarding the circumstances and ask for reconsiderations of the decision. Nonetheless, any uncertainty will be resolved in favor of TOPH’s commitment to provide a safe and peaceful environment.

Individuals who have criminal convictions involving drugs, sexual misconduct, or violence will generally be denied access to The Our Promise House.  The following is an illustrative, but not exhaustive, list of such convictions:

• Sexual predator crimes – all offenses

• Sexual misconduct, including sexual battery

• Murder/manslaughter

• Child abuse, aggravated child abuse

• Kidnapping

• False imprisonment

• Lewdness/indecent exposure

• Voyeurism and video voyeurism

• Luring or enticing a child

• Terrorism

• Arson

• Burglary

• Any crime against a person (i.e. aggravated assault, battery, robbery, home invasion robbery, carjacking, domestic violence)

• Fleeing from a criminal institution

• Resisting arrest with violence

• Any felony or multiple misdemeanor (s)drug conviction(Including: illegal sale and delivery of narcotics, drug manufacturing/cultivation, possession, trafficking, distribution)

• Prostitution

• Stalking

If you have failed the background check, you will need to find other accommodations. Other individual members of your family/group may be permitted access to our facilities with a passing background check. The background check will be performed by Alliance Background. The toll‒free telephone number that you can use to contact Alliance Background is 1-866-590-8715. Alliance Background’s address is 12651 Walsingham Rd Ste. C, Largo, FL 33774. You have important rights under the Fair Credit and Reporting Act that you can exercise by contacting Alliance Background. If Alliance Background reports negative information to us causing you to fail our background check, you can obtain a copy of your report from Alliance Background free of charge. You can dispute any inaccurate, incomplete, or out‒of‒date information in Alliance Background’s Report by contacting Alliance Background. If you do, Alliance Background will re‒investigate the information that you dispute, remove or correct any inaccurate or incomplete or out‒of‒date information, and send us a replacement report. Alliance Background will also take steps to prevent any inaccurate or incomplete or out‒of‒date information from appearing in any future reports they prepare about you.

In addition to this policy, TOPH reserves the right, in its sole discretion, to expel a guest for any inappropriate, irresponsible or criminal behavior that takes place while temporarily residing at one of our Houses. While TOPH has implemented this background check policy in order to take reasonable efforts to protect the safety of our guest families, TOPH cannot and does not warrant or guarantee the personal safety of any temporary resident, guest, visitor or staff member.

Please confirm that you agree to have a background check and that you have read the above.

HEALTH SCREENING

Although The Our Promise House is not a healthcare facility, it is a ‘residence’ with potential for exposure to infectious diseases. Patients with medical conditions that make them particularly vulnerable to infection live in and share common facilities with many other children and their families. Such communal living can provide opportunities for the transmission of infectious agents if caution is not taken. By understanding the principles of prevention of infection transmission, all individuals who live and work in such facilities can reduce the risk of infection for children and families who they serve(1).

Below are health screening questions to be completed by each family. Some specific illnesses of epidemiological significance require a signed medical clearance document, confirming that the family members are not an infectious risk to guests, staff, and volunteers. The document should be completed by a healthcare provider who is familiar with the person’s medical condition(2). Should a document be needed, The Our Promise House (TOPH) Staff can provide a standardized form to be completed by the appropriate healthcare provider.

Please confirm that you have read and understood the above.

Please answer YES or NO to the following questions:

Have you or anyone in your family (those staying at TOPH) had any of the following:

CHICKEN POX STATUS

Please confirm that you have read and understood the above.

Primary Guest Name

THE OUR PROMISE HOUSE EXPECTATIONS

Elgibility and Length of Stay

All adults 18 or over must have a valid state or federal photo ID upon check-in. After patient's discharge from the hospital, your family must check out of TOPH the same day. Families are required to check out of TOPH for 2 nights between stays and may request to be placed back on the waiting list for a room if the patient is still receiving active treatment (Re-admittance will be based on availability and Manager’s approval). Families are required to spend the majority of their time during their TOPH stay at the hospital to be with their patient and have active engagement with their medical plan.Verification for daily patient visits is required. A Guest Pass must be picked up from an TOPH Staff Member, validated by the patient's healthcare provider and turned in daily. Your room must be used every day. You are required to check out and may request to be placed back on the waiting list if you do not use your room daily. TOPH staff reserves the right to do random inspections of rooms, enter rooms for maintenance issues or in the event of an emergency. There is no cost to stay at the TOPH, but donations of as little as $20 a night can help sustain our services so that we may be able to help future families in need. Families must maintain an active permanent physical address while staying at the House.

The following activity and behavior is strictly prohibited and will be cause for disciplinary action up to and including lost of current eligibility:

Smoking, including e-cigarettes and vaporizers

Possession or use of ALCOHOLIC BEVERAGES, ILLEGAL DRUGS (as defined by Federal law), or FIREARMS in or on this Ronald McDonald House property

Domestic Disturbances (including physical or verbal abuse)

Disorderly or public intoxication

Loud, offensive, or disrespectful language

Theft of any kind

Smoking, including e-cigarettes and vaporizers

Possession or use of ALCOHOLIC BEVERAGES, ILLEGAL DRUGS (as defined by Federal law), or FIREARMS in or on this Ronald McDonald House property

Domestic Disturbances (including physical or verbal abuse)

Disorderly or public intoxication

Loud, offensive, or disrespectful language

Theft of any kind

Visitors

Visitor is defined as—A Secondary Person to the Primary Caregiver or Support Person that is not spending consistent or extended time at the house.

Please make TOPH Staff aware of visitor arrivals in advance.

Visiting hours are between 10AM-8PM daily.

Visitors are required to sign in and out.

‘Visitors’ must be in the presence of the Primary Caregiver or Support Person that they are visiting at all times and may not have access to a key card.

Parking

TOPH Parking is in the TOPH parking lot; please see Manager for more details.

Please do not park in the spaces marked for TOPH Volunteers and Staff.

Kitchen, Common Areas, and Bedrooms:

Quiet hours are between 9PM – 9AM. During these hours, we expect Guests to lower the volume of their televisions and keep conversations at a normal volume level. Tampering with or propping open doors at the TOPH is prohibited. Parental supervision of children and teenagers under the age of 18 is required at all times within the House and, when applicable, in the outside courtyard, balconies, and playground spaces. Children and teenagers are not permitted to be left with another TOPH guest or any individual outside of the registered guests listed for your room. An adult should be within arms length of infants, toddlers, and young children at all times. Appropriate clothing and shoes must be worn by all guests & visitors in kitchen and common areas at all times. All food and beverages must remain within the kitchen and dining room areas. No food or beverages are allowed in the guest rooms with the exception of water. Families are required to clean up after themselves in the House. No animals or pets are allowed on the property of the TOPH with the exception of a certified service dog. Outside health providers are not allowed to perform treatments or procedures of any kind on the TOPH premises.

Check out Procedures:

Families are required to clean their room prior to checking out, see procedures in Guest Binder. A room inspection by an TOPH Staff Member will take place at check out. Room keys must be returned at check out. Improper check out and/or room cleaning procedures may affect the future eligibility to stay at TOPH. Any House Expectation violations will be documented by TOPH Staff and discussed with all parties involved in violation. Documented violations will be used by TOPH Staff to determine a guest’s current and future eligibility for The Our Promise House Charities. This facility is protected by video surveillance.

⋆Please note that the primary caregiver, support person(s), and visitors are responsible for understanding and abiding by House Expectations.

Hold Harmless Agreement

I desire to stay at The Our Promise House. In consideration for staying at the House, Guest agrees to release, waive and forever discharge The Our Promise House. (“TOPH”), its officers, employees and agents from any liability, actions, causes of action, damages, claims, and demands of every kind and nature whatsoever arising out of or resulting from Guest’s stay at the House or from Guest’s employees, officers, affiliates, family members, members, agents, invitees, licensees, visitors or other parties (collectively “Guest Parties”) stay at and/or visit to the House. Further, Guest agrees to defend, indemnify, and hold harmless TOPH, their officials, agents, and employees from and against any and all claims, suits, judgments, demands, liabilities, damages, costs and expenses (including attorney’s fees) of any kind or nature whatsoever related to this paragraph arising directly or indirectly out of or caused in whole or in part by any act or omission of Guest, its directors, officers, employees, agents, family members, members, contractors, invitees and visitors, anyone directly or indirectly employed by them, or anyone for whose acts any of them may be liable. This paragraph shall be binding upon Guest and its heirs, personal representatives, successors and assigns.

Please confirm that you have read and understood the above

Name of Primary Guest agreeing to all of the above and acting as responsible party for all individuals in the family who are applying for temporary lodging at The Our Promise House, Hot Springs, Arkansas.