Stay at Hope House

Please complete this application form for consideration to stay in Hope House Ireland. All details submitted are strictly confidential.

Step 1: Address and contact details

Application Form Submitted by:

Details of person with Cancer diagnosis

Patients Forename

Patients Surname

Date of Birth

Address Line 1

Address Line 2

County

Postcode

Home Telephone Number

Mobile Telephone Number

Email Address

Step 2: Diagnosis Details

What type of Cancer?

Date of Diagnosis

Is treatment still ongoing?

Main Consultant's name

Hospital attending

Will you require someone else to stay with you

Guests Forename

Surname

Relationship

Contact Number

Step 3: Additional Information

Extra Info

Do you consent to Hope House storing your information? See terms and conditions.YesNo

I agree to the terms and conditions.

We take our data privacy responsibilities very seriously and are committed to protecting your privacy. It is important to us that you understand and feel confident about how we collect, store and handle your personal data. Our new Privacy Policy explains this and also the rights you have in relation to your personal data.