A Better Night's Sleep Application Step 1 of 5 20% Participation in this program is limited and will be filled on a first come, first served basis. Please allow two full weeks to HCC Staff to process all applications. At the end of this application you will be asked to upload the following documents. Please be prepared with pdf, png, gif or jpg copies of these files. A hand written letter stating why you need beds A copy of each child’s birth certificate OR proof of guardianship (Social Security Cards & Passports are NOT accepted) A copy of your valid photo ID A copy of your rental agreement A copy of your most current electric bill or most current phone bill A copy of food stamps letter, Medicaid letter, or any other form of government assistance You will receive an email once your application is reviewed and processed detailing next steps. If your contact information changes (phone number or address), please call our office to update your information. By submitting this form you also agree to allow pictures of you and/or your children in any HCC publication.Contact InformationName* First Last Spouse Name First Last Address* Street Address Apartment # City TX AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Enter Email Confirm Email Home PhoneCell Phone*Work PhoneExtension Additional InformationMarital Status* Married Single Parent Divorced Separated Living Together Language* English Spanish Race/EthnicityWhiteHispanic or LatinoBlack or African AmericanAsianAmerican Indian or Alaska NativeOtherRent Amount*Landlord's PhoneMonthly Household Income*Please include any government assistance. Please list your children's Information below:Have you been awarded beds from Houston Children's Charity within the last 12 months?YesNoHow many children are in your Legal Custody?*12345678910How many beds do you need?*01234Child/ Children must be between ages 4 and 18. There is a limit of 4 beds.Child's Name* First Last Age*456789101112131415161718Birth Date* MM slash DD slash YYYY mm/dd/yyyyGender* Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Birth Date MM slash DD slash YYYY mm/dd/yyyyGender Male Female Child's Name First Last Age456789101112131415161718Gender Male Female Birth Date MM slash DD slash YYYY mm/dd/yyyy Please provide the following documents:A copy of your valid ID* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A hand written letter stating why you need beds* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of your rental agreement* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of your most recent electric bill or most recent phone bill* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of food stamps letter, Medicaid letter, or any other form of government assistance* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of each child's birth certificate and/or proof of guardianship (Social Security Cards & Passports are NOT accepted)* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. Waiver & Release of Liability, Assumption of Risk, and Indemnity Agreement*In return for being allowed to participate in ANY of Houston Children’s Charity programs, including any activities incidental to such participation, I hereby voluntarily and knowingly agree to release, indemnify, defend, hold harmless, and covenant not to sue Houston Children’s Charity, and its officers, directors, staff, employees, sub-contractors, sponsors, agents, volunteers, and affiliates for any and all liability, claims, costs, and causes of action, including, but not limited to, any claim arising out of the ordinary negligence of any of the foregoing, that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death that may be sustained by me arising as a result of my participation in program services offered by Houston Children’s Charity, or while on the premises owned or leased by Houston Children’s Charity. I understand and agree that Houston Children’s Charity is not responsible for any injury or property damage arising out of my participation in the program services, even if caused by Houston Children’s Charity’s ordinary negligence or otherwise. I understand that participation in the program services involves certain risks, including, but not limited to, serious injury and death. Therefore, I assume all risks, including, but not limited to, the risks associated with slipping, falling, tripping, shifting of heavy objects or furniture, loading or unloading vehicles, operation of equipment or tools, or sustaining any type of related injury in connection with my participation with Houston Children’s Charity. I am voluntarily participating in the program services with knowledge of the danger involved and I agree to accept all risks of participation, even if arising from the negligence of others. I am of legal age and am freely and voluntarily signing this agreement without any inducement, assurance, or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. I have read this WAIVER & RELEASE OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT and understand that by signing this form, I am giving up legal rights and remedies. I agree CAPTCHA Δ
