Megan's Home Application

Referral Information

All Requests for Megan's Home must be sent by an In-Service Medical Social Worker or Hospital Designee, after being completed by a parent or guardian of the Patient. Rent is $20/Day and family can stay up to 3 months with qualifying need. Please submit the application and send any supporting documentation by fax or email to ksavage@meganswings.org. If you require additional assistance please call Kim Savage at 909-532-8135. No admissions after 7pm Unless Emergent.

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* 1. Patient Information:

Patient's Full Name:

Date of Birth:

Gender:

Current Hospital:

Reason Why Patient Needs to Stay In Megan's Home:

Diagnosis:

Date of Diagnosis:

Inpatient or Outpatient:

Treatment:

Attending Physician:

Medical Social Worker Name:

Medical Social Worker Email:

Medical Social Worker Phone Number (please include extension):

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* 2. How Many Miles Is Family Traveling For Treatment from Their Home to Hospital?

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* 3. Parent/Guardian Information

Parent/Guardian Name:

Reliable Phone Number:

Parent/Guardian Name:

Reliable Phone Number:

Permanent Home Address:

How Long At This Home:

Email Address:

Alternate Phone Number:

Are Parents Working:

Job Title:

Total Monthly Income:

Do Both Parents Live In The Home:

Language Spoken In The Home:

How Many IMMEDIATE Family Members Will Stay In The Home:

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* 4. Occupant Information - (Not Including the Patient)

Occupant #1 - Full Legal Name, Relationship to Patient, and Age:

Occupant #2 - Full Legal Name, Relationship to Patient, and Age:

Occupant #3 - Full Legal Name, Relationship to Patient, and Age:

Occupant #4 - Full Legal Name, Relationship to Patient, and Age:

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* 5. Move In Information:

Date of Move-In:

Approximate Time:

Estimated Departure Date:

Can The Family Pay A Security Deposit of $200?

Can The Family Pay a Daily Rate of $20?

Does The Child Qualify for California Children's Services (CCS)?

CCS #:

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* 6. Provide brief explanation of patient situation and financial hardship:

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* 7. I Have Personally Read and Explained the Guidelines to This Family?

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* 8. The following paragraph is to be read and completed by parent/guardian of patient:
I have read the rules and regulations and agree to adhere to the rules set forth by Megan's Wings, Inc. If I do not follow MW's rules and regulations, I am aware I may be asked to leave. I agree to release the above information to Megan's Wings, Inc. I also give permission for the hospital and Megan's Wings to share information when the patient is discharged, deceased, transferred, receiving home health services, or about our families eligibility to stay at Megan's Home. Family acknowledges that this is a temporary home away from home. Family is not allowed to use the HOA pool and agrees to not hold Megan's Wings, Inc. responsible for any accidents that may occur at the temporary home, or surrounding areas. Parent/Guardian MUST sign this form before Megan's Home can be occupied.

NOTE: Rent is $20/day to stay at Megan's Home. If your child has CCS, they may qualify for 15 of 30 days rent by CCS. A $200 security deposit is required and will be reimbursed within 30 days after the family vacates the property if the property is left in it's original move-in condition. Repair or replacement of damaged items or services needed, due to not caring for the home will be deducted from your security deposit. If repair/replacement/maintenance costs are more than the deposit, the family will be billed for the remainder. Megan's Wings is a 501c3 charity, Tax ID #56-2501762