RMHC of the Southwest

Patient's Name: *

First

Last

For office purposes.

Checking each of the rules listed below indicates your acknowledgement of receipt of this information and your family's agreement to uphold these rules throughout your stay at RMHC. *

1. Smoking or the use of any tobacco product is not permitted anywhere in the RMHC Family Room or Sleep Rooms.
2. No weapons, alcohol, or illegal drugs will be allowed to be used, consumed, or stored anywhere on the RMHC property, "Pursuant to Section 30.06, Penal Code (trespass by holder of license to carry a concealed handgun), a person licensed under Subchapter H, Chapter 411, Government Code (concealed handgun law), may not enter this property with a concealed handgun."
3. Child abuse, domestic violence, or obscene language and gestures will not be tolerated.
4. Guests are required to clean up after cooking, eating, and drinking.
5. It is your responsibility to complete the check-out procedures checklist so that the room can be made ready for the next family.
6. In the event that the room will be unoccupied for more than one night, guests must properly check-out of the room and ask to be put back on the waiting list for the date of their return.
7. You must notify the staff of the departure or arrival of any guest or visitor staying in the room.
8. RMHC rooms will accommodate a maximum of 2 guests.
9. Registered guests are limited to immediate family members or primary care-givers of the patient.
10. Children under the age of 15 must be supervised by a parent or guardian at all times.
11. People exposed to or having contagious illnesses may be required to vacate the RMHC Family Room and Sleep Rooms. Guests who have been diagnosed with a contagious illness must notify staff immediately.
12. Guests are required to cooperate fully with the staff in providing information and assistance required to obtain third-party reimbursement, (i.e., Medicaid).
13. Loud or disruptive behavior is not allowed at any time. Quiet hours are from 10:00 PM to 7:00 AM.
14. Appropriate dress must be maintained at all times. Offensive or revealing clothing should not be worn. Guests must be fully clothed (if in pajamas, this includes a robe) with shoes or slippers.
15. RMHC will not be responsible or liable for any loss of or damage to personal property or for any personal injuries, illnesses, or deaths, even in the event of negligence.
16. Staff of RMHC has the right to make random room checks at their sole discretion.
17. Access to each guest room is mandatory for daily cleaning (sweeping and trash collection), to be performed by cleaning staff.
18. If my child is not in Intensive Care, I understand that I may be asked to vacate my room in the event that the sleep rooms are full and other families of critically ill children need lodging.
19. After 30 days, RMHC reserves the right to review sleep room occupancy, the family's adherence to rules and policies, and other factors deemed relevant in order to authorize or decline additional nights.

Lodging at RMHC is a privilege and not a right. All guests are expected to abide by the rules of RMHC AND to act responsibly in all instances, which may or may not be outlined in this document. Failure to do so may result in being required to immediately vacate the RMHC Family Room and Sleep Room based on the discretion of the staff. *

I authorize the RMHC to receive or communicate any information concerning the patient with any medical institution.
I have read and understand the guest rules and agree to abide by them.
I also agree to be responsible for my family and visitors.

Do you or any of your guests have an open or pending CPS case? *

Yes
No

Have you or any of your guests been convicted of domestic violence or the subject of a pending domestic violence case? *

Yes
No

Are you or any of your guests a registered sex offender? *

Yes
No

Are you or any of your guests currently in an open or pending court case regarding criminal activity including, but not limited to, alcohol, drugs, or theft? *

Yes
No

Have you or any of your guests ever been convicted of any felony or misdemeanor? *

Yes
No

I further authorize Ronald McDonald House Charities to produce and make use of any photographs or videos of the patient, my family, and myself for the purpose of publicizing the services and work of RMHC of the Southwest, without any compensation to us or retention of any ownership or other rights.

Yes, photographs and videos can be used for publicity, promotional materials, fundraising proposals, and printed media.
Yes, photographs and videos can be posted on the web site or RMHC social media for promotional purposes.
Do not use photographs and videos for publicity, promotional materials, fundraising proposals, or printed media.
Do not post photographs or videos on the web site or RMHC social media for promotional purposes.

Signature

Date Signed: *

Please enter in MM/DD/YEAR format (ex.: 07/16/2020)

Keeping families close

GUEST RULES AND AGREEMENT