HOUSING APPLICATION

 
The Live4Evan Organization offers three, fully furnished apartments directly next to Boston Children’s Hospital (BCH) in the Longwood Galleria Apartment building. The apartments are reserved for families whose children are receiving cardiac care and traveling more than 50 miles from BCH. The maximum occupancy for each apartment is 4 people.

If Live4Evan is able to accommodate your stay, you will receive a lease agreement and instructions for submittal of funds required to complete the application process.

There is a $40 per night charge for staying in the Live4Evan apartment. An initial fee of $200 will also be required upon completion of the application process and signing of the lease agreement.


PATIENT INFORMATION

Patient’s First Name:

Patient’s Last Name:

Patient’s Age:

Diagnosis / Reason for Current Trip:

APPLICANT INFORMATION



















Primary language:

HOUSING NEEDS

How many family members will be staying?:

Names/ages of family requiring housing:

Anticipated arrival date:

Anticipated departure date:

Special Needs / Accommodations Required:

CURRENT TREATMENT INFORMATION

Social Worker Name:

Social Worker Email:

Social Worker Phone:

Home Hospital:

Treating Doctor:

BY CLICKING SUBMIT YOU ARE AGREEING TO THE FOLLOWING:

  • Live4Evan requires that all families housed in our apartment also maintain a permanent residence to return home to. By clicking submit, I hereby certify that the address above is the permanent residence for my family, and agree to notify Live4Evan immediately if that changes.
  • Live4Evan requires confirmation by a social worker at BCH that applicants already have appointments/procedures scheduled prior to approval for housing. By clicking submit, I hereby certify BCH to confirm or deny that my child has appointments scheduled in the Heart Center.