Our Promise House

Application Form

Please fill out the form below to apply for housing in The Our Promise House.

Patient Information

Please fill out patient information only

First name

Last name

Phone

Preferred Method of Contact

Phone

Birthday

Gender

Diagnosis Category

Diagnosis

Physician

Social Worker or Hospital Representative

Hospital

Patient Status

Primary Guest Details

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

First Name

Last Name

Date of Birth

Relationship to Patient

When do you need to stay with us and for how long?

Less than 6 days

7+ days

30 days or longer

Physical Address

Your current physical address

Address

City

State

Zip Code

Emergency Contact

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

Name

Phone

Relationship

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.

First & Last Name

Date of Birth

Email Address

Relationship to Patient

Transportation

Does the Family have transportation?

Vehicle Details

Will you have a vehicle on premises?

Yes

Vehicle Make & Model

License Number

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.

Our Promise House (“OPH”), 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 OPH solely will obtain a background check to assist in determining whether to grant you access to our facilities. OPH is not obtaining a “consumer report” for any other purpose. OPH 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.

OPH 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 OPH. OPH 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 OPH 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.

OPH 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