FR Visitor Sign In Form

Visitor Sign In Form

Ronald McDonald House Charities of Southern Colorado
Have you visited the Family Room within the last year?*

Yes / síNo / no
Date and Time of Arrival*

MonthDayYear
Date / Fecha
Hour and Minutes / Hora y Minutos AM/PM Option
Your Name*

First Name / Primer NombreLast Name / Apellido
Your Relationship with the Patient*
Do you want to receive future mailings from RMHCSC?*

Yes / síNo / no
Your Street Address*

Street Address / Dirección Postal

Street Address Line 2 (optional) / Dirección Postal Linea 2 (opcional)

CityState / Province

Postal / Zip Code
Your City, State, and Zip Code*

Street Address

Street Address Line 2

City / Cuidad State / Estado

Zip Code / Código Postal
Excluding yourself, how many ADULTS are in your group? (age 18 and above)*
How many CHILDREN are in your group? (age 17 and below)*
Patient Information

Información del paciente
Is there more than one patient?*

YesNo
Patient's Full Name*

First Name / Primer Nombre Last Name / Apellido
Patient's Date of Birth*

MonthDayYear
Date / Fecha
What hospital department is the patient in?*
Ethniticy of Patient (select one or more)*

Native American or Alaska Native / Indio Americano o Nativo de AlaskaAsian / AsiáticoBlack or African American / Negro o Afro-americanoHispanic or Latino / Hispano o LatinoWhite / CaucásicoOther or Decline to Provide / Otro o Declino a responder
Gender of Patient*
SECOND Patient's Full Name*

First Name / Primer Nombre Last Name / Apellido
SECOND Patient's Date of Birth*

MonthDayYear
Date / Fecha
THIRD Patient's Full Name (if applicable)*

First Name / Primer Nombre Last Name / Apellido
THIRD Patient's Date of Birth (if applicable)

MonthDayYear
Date / Fecha
How did you hear about the RMHC Family Room?*
Should be Empty:

Visitor Sign In Form

Patient Information