Referral Form Eleanor Referral Form Families of Patients Guest Testimonials Send A Notecard Referral Form Have you stayed with us in the past? YesNo Patient Information Gender MaleFemale BackNext Guest Information Vehicle Information Will you have a vehicle kept on campus? YesNo BackNext Stay Agreement Please check each box. I accept responsibility for any and all damages caused to Quantum House or its contents by me, any member of my family or my guests.I understand that I enter Quantum House at my own risk and that Quantum House is not responsible for my possessions or any personal injury to me, any member of my family or my guests.If I violate any of the rules and regulations, I understand I will be asked to vacate Quantum House, and I forfeit my privilege to stay at Quantum House in the future.I understand alcohol, illegal drugs and smoking are NOT permitted in Quantum House or on the St. Mary’s campus at any time.I understand that Quantum House does not provide maid service and I am responsible for cleaning my guest suite weekly and at check out.I will be expected to thoroughly dust, vacuum & clean my entire guest suite including wash my own linens on a weekly basis.At check out – I am expected to return the room to its original condition with the exception of the beds and towels. All dirty linens should be left in the assigned laundry basket and dropped off in the laundry room when you leave.There is a $40.00 per night, per room, guest fee to be paid weekly or if your stay is shorter than a week, please pay at checkout.A valid driver’s license or valid photo ID is required for each guest in the house and will be kept on file.Background checks may be run on potential House guests prior to being accepted as guests.No solicitation of any kind is permitted while staying at Quantum House. Have you ever been convicted of a felony? YesNo Download a copy of the referral form.