Additional Guest Form

Patient's LAST name (21 or younger) *

Patient's FIRST name (21 or younger) *

Guest Full Name (person staying at RMHC) *

Relationship to Patient *

Email

Phone Number

Area Code Phone Number

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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? *

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

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

Chicken Pox Status *

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

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? *

Yes No If yes, which symptom?

Have you been exposed to anyone with COVID-19 in the last 10 days? *

YES NO

If yes to exposure, did you have a negative test at least 5 days after your exposure? (leave blank if answer was no)

YES NO

Have you been isolating or quarantining because you tested positive for COVID-19 or are you worried that you may be sick in any way? *

YES NO

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

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

Name of parent/guardian

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. Anyone in possession of a weapon will be asked to leave.

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; any guest will be asked to leave.

3. Food – The kitchen and dining room is fully open with no closed tables. Please utilize your designated locker and refrigerator in the kitchen to store personal food. Also, families should eat in the dining room whenever possible, but eating in guestrooms will still be allowed. Always dispose of plates etc. ASAP. You may use the kitchen trash cans to dispose of food. Do not leave any open food in your guestroom. Cooking is allowed 7am- 9pm. Nothing should be left in the sinks, on the stoves or the counter tops. 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 and secure your valuables; RMHC is not responsible for lost or stolen items

6. Visitors – At this time our building is closed to all visitors. Only approved guest families and staff are allowed in the building.

7. Occupancy - The room MUST be utilized DAILY. Prior approval must be obtained from the Manager on duty in order 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.

8. Proper Attire – Socks or shoes must be worn at all times in common areas and modest clothing is encouraged.

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

10. Children – Families must try to make other arrangements for siblings and other children. When it is impossible, they will be allowed. When family support is needed to care for siblings, the individual will be considered on a case-by-case basis. Children (13 years of age or younger), must be accompanied by a parent or guardian at all times 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 the kitchen 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 your room only. Failure to occupy your guest room each night may result in losing your room at Ronald McDonald House.

16. Health & Safety - Anyone, with suspected COVID 19 or any other illness must depart/check out as quickly as possible. Informing staff of illnesses, suspected illness, or COVID-19 exposure is required. Anyone who has exhibited symptoms or has been tested and is awaiting their results should be presumed positive for COVID 19. Once test results come back negative and/or they can present proof of being cleared by a medical facility they may check back in with proof of 14- day self-quarantine. 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. DCD mask guidelines will be enforced.

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.

Guest Health Screening

Please answer YES or NO to the following questions.

COVID 19 Screening

Grant, Assignment, Release and Waiver (Can we take your picture?)

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