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HOME
ABOUT
Ronald McDonald House
Our Relationship with McDonald’s
Family Rooms
Care Mobile
Grants and Scholarships
Chief Cheer Officer, Jax
Hopeful Healing Hearts
GET INVOLVED
Volunteer
RMHC MERCH
Ways To Give
Guest Chef Information
EVENTS & NEWS
Meal Calendar
RMHC Calendar
Press Room
Newsletters
Family Stories
CONTACT
Career Opportunities
Background Check Consent
R Westfall
2020-08-18T02:45:11-05:00
BACKGROUND CHECK CONSENT
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Patient's Name
*
First
Last
For office purposes.
Name: First, Middle, Last
*
Maiden / Other Names Used
*
Enter N/A if this field does not apply to you.
Date of Birth
*
Please enter in MM/DD/YEAR format (ex.: 07/16/1972)
Drivers License / State ID #
*
Photo ID Upload
*
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Please take a photo of your drivers license (preferred) or some photo ID and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.
Social Security #
*
Social Security Card Upload
*
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Please take a photo and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.
Address
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*
Relationship to Patient
*
By signing this form, you are swearing that the information you have provided is true and correct to the best of your knowledge; you are giving permission for a security check to be run, including a criminal background; you are consenting to RMHC sharing acquired information with relevant medical facility personnel; and you are agreeing to conform to all policies and regulations as stated in the Guest Rules.
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