GUEST REGISTRATION FORM

Patient's LAST Name (Child Receiving Treatment) *

Patient's FIRST Name (Child Receiving Treatment)*

Patient's D.O.B*

Date

Gender*

Please indicate the patient's (child's) ethnicity/race by selecting one of the options below*

Expected Date of Departure (How long will your stay with us be?)*

Date

Medical Facility

Department*

Diagnosis*

Guest Name (your name)*

Relationship to patient*

Date of birth *

Date

Email*

Home address*

City*

State*

Zip*

Best phone to be reached at*

Car Make / Model / Color

Tag #

Are you a repeat guest?*

Do you or any of your guests smoke?*

Fever higher than 99.5º (37.5ºC) in the past 2 days?*

Vomiting in the past 2 days?*

Stiff neck or headache with a fever in the past 2 days?*

Diarrhea in the past 2 days?*

Current skin lesions that are "weepy" (Fluid or pus-filled)?*

ANY current skin rash?*

Current cold or flu symptoms (runny nose, cough, congestion)?*

Exposure to Tuberculosis (TB) in the past 2 months?*

Chicken Pox Status*

	Yes	No
Have you had chickenpox of shingles before?
Have you been vaccinated against chickenpox (varicella)?

Exposure to any of the following within the past 3 weeks: *

	Yes	No
Chicken Pox
Household member with head lice
Measels
Mumps
Whooping Cough

Are you experiencing any kind of illness, even light symptoms including (but not limited to) fever, cough or shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting, or diarrhea in the past 48 hours?

YESNOIf yes, which symptom?

Have you been isolating or quarantining because you tested positive for COVID-19 or are any other illness?

YESNO

I have read and agree to the Grant, Assignment, Release and Waiver*

I agree to the Grant, Assignment, release and waiver.

Name (only sign if guest is a minor)

From time to time, RMHC materials are shared for McDonald’s promotional purposes to demonstrate their support of RMHC. Please check this box if you prefer that we not share your information/images.

I prefer that RMHC not share my information/images with McDonald's

I have read and agree to the Legal Liability Release Agreement.*

I agree to the Legal Liability Release Agreement

I have read and agree to the Confidentiality and Exchange of Information*

I agree to the Confidentiality and Exchange of Information

1. Substance Abuse & Weapons – The use of alcohol & illegal drugs are strictly prohibited in or around the house. Anyone under the influence (as determined by the on-duty Manager) will be asked to leave. Weapons are strictly prohibited in or around the house.

2. Smoking – Smoking within the house, on decks, at entrances, in the parking areas, or in the playground is strictly prohibited. Smoking is permitted ONLY in the gazebo around the side of the building off the parking lot. Violators will lose their room at Ronald McDonald House.

3. Food –Food and drink are allowed in the kitchen, dining room and patio area. Please refrain from having food in the guestroom. Utilize your designated locker and refrigerator in the kitchen to store personal food. Cooking is allowed 7am- 9pm. Clean up after yourselves throughout the House. Nothing should be left in the sinks, on the stoves or the countertops. All dishes must be rinsed and then placed in the dishwasher to sanitize them.

4. Candles – No candles or incense are allowed in the guestrooms.

5. Security – DO NOT give access code or open doors to anyone who is not a registered guest. Please report any suspicious activity immediately to the on-duty Manager. Secure your valuables during your stay, RMHC is not responsible for lost or stolen items.

6. Visitors – Visitors are allowed at designated times. Registered guests must be in the House while visitors are present unless the manager on duty is notified. Visitors will sign-in and wear a name tag.

7 Wristbands – Each registered guest of RMHC should always wear a red RMH wristband. This makes registered guests easily identifiable to staff and ensures the safety of each person staying at RMH.

8. Occupancy - The room MUST be utilized DAILY. Prior approval must be obtained from the Manager on duty to leave the room vacant overnight. Leaving room vacant without approval may result in losing your room. All overnight and respite guests must be registered, all people 19 and older must complete and pass a background check before utilizing RMHC of Mobile. NO pets allowed.

9.Proper Attire – Socks or shoes must always be worn in common areas and modest clothing is encouraged.

10. Children – Siblings are welcome but must be registered. Children (13 years of age or younger) must always be accompanied by a parent or guardian while at RMHC. Children (13 years of age or younger) are not to be anywhere in the house without an adult. Children (ages 14 – 18) are allowed to be in the house without adult supervision, but their parent and/or guardian must be in the building at RMHC, when the adult leaves the building, the child must accompany them.

11. Cleaning – Each family is responsible for keeping their room and the common areas clean. Cleaning supplies are available under the bathroom sinks or can be obtained by asking a staff/volunteer. Vacuum cleaners and brooms are available in the janitor’s closets located on each floor. Please return them to the janitor’s closets when finished. Please take trash out as often as needed. The trash container is located across the street at the back of the parking lot. You are responsible for cleaning your room at time of check-out. Please see Check Out Procedures.

12. Laundry – Families may use the laundry room during their stay for personal use. Please don’t leave laundry unattended. Remember to sign up, 1 family per time slot.

13. Misconduct/Harassment – Disruptive & unruly behavior, or general misconduct (as determined by the on-duty Manager) is prohibited and may result in loss of room. Harassment of any guest, visitor, staff, or volunteer is strictly prohibited and will result in eviction and notification of the police. Any intentional infliction of pain and corporal punishment are NOT allowed. If you are subject to any harassment, please contact Management.

14. Parking – The parking lot is located across the street. The parking spots in front of the house are reserved for handicap individuals and loading and unloading. Vehicles should be registered with office.

15. Daily Sign In – Each family must sign in at the reception desk daily for the assigned guest room only.

16. Health & Safety - Anyone with suspected COVID 19 or any other illness must depart/check out as quickly as possible. Any family member being referred with a child in the hospital suspected of having a communicable disease must be cleared by the medical staff who is currently involved in the child's medical care by completing the Medical Clearance Form.

Note: The House staff reserves the right to enter any guest room for routine or emergency maintenance, general inspection of facility, or any other reason. The House reserves the right to deny entrance to any guest or refuse continued occupancy because of past conduct or violation of the House Guidelines Management must approve exceptions to these guidelines in advance.

I have read and agree to the House Policies.*

By checking this box you are verifying that you have read the HOUSE GUIDELINES in full.

NAME

Relationship to the Patient

Age (Minor only)

NAME

Relationship to the Patient

Age (Minor only)

NAME

Relationship to the Patient

Age (Minor only)

PATIENT'S INFORMATION

GUEST INFORMATION

Guest Health Screening Questions

Health Screen

Grant, Assignment, Release and Waiver

I represent that I am a parent or legal guardian of the person(s) identified above, who is/are a minor(s). I consent to the use of his/her name, voice, likeness and/or other identifiable representation of him/her as set forth above.

Legal Liability Release Agreement

Confidentiality and Exchange of Information

House Guidelines

Additional Guests - OPTIONAL

GUEST #2 - Approved minors only.

GUEST #3

GUEST #4