Cotton Foundation

Who we can reach

The person we should contact about this application.

Your full name Please enter your full name.

Your relationship to the family Please tell us how you’re connected to the family.

Email address Please enter a valid email address.

Phone number Please enter a phone number we can reach you at.

How would you prefer we reach you?

Phone callWe’ll call the number above Text messageA short text to start EmailWe’ll write to you first

Please choose how you’d like to be contacted.

Best time to reach you

City Please enter your city.

State Please enter your state.

Your family

Tell us who would stay at Taylor’s Place. Share as much or as little as you’re comfortable with.

Family name The family who would stay, for example “The Wallace family”. Please enter the family’s name.

Name of the family member facing illness First name is fine. Please tell us who the stay is for.

Adults How many adults would stay?

Children How many children would stay? Enter 0 if none.

Children’s ages optional

Tell us about your family, and what a stay at Taylor’s Place would mean to you. A few sentences is plenty. This is the part we read first. Please share a few sentences about your family.

Is there anything about your family member’s care we should know to make the stay comfortable? optional Mobility, medical equipment, dietary needs, accessibility, or anything else that would help us prepare the house.

Is your family currently working with a hospice, hospital, or care team?

Yes No

Please let us know.

Your stay

When you hope to come, and what your family would enjoy. Nothing here is binding; we’ll settle the details together.

When would you hope to visit?

As soon as possibleWe’ll prioritize the conversation Within the next 1–3 months A specific month We’re flexible

Please choose the timing that fits best.

Which stay works best for your family? Every stay is three days and two nights.

Monday – Wednesday Tuesday – Thursday Friday – Sunday Not sure yet

Please choose a stay, or “Not sure yet”.

What would your family enjoy? choose any

Fishing on the pond The pool Picnics outdoors Games and movies Music Basketball or pickleball The playground Simply resting together

Anything else you’d like us to know? optional

How did you hear about Taylor’s Place? optional

Review and submit

Check that everything looks right. You can go back and edit any section.

Before you submit

The information in this application is accurate to the best of my knowledge. I understand that submitting this application does not guarantee a stay, and that a member of the Cotton Foundation will reach out to talk with me personally. I consent to the Cotton Foundation contacting me by the method I chose, and I have read the Privacy Policy.

Please confirm each statement to continue.

Your application is sent securely to the Cotton Foundation and is read only by the people who arrange stays at Taylor’s Place. We never share it.