Skip to content
Office: 806.744.8877
|
Fax: 806.744.3652
VOLUNTEER
DONATE
Keeping families close
HOME
ABOUT
Ronald McDonald House
Our Relationship with McDonald’s
Family Rooms
Grants and Scholarships
Hopeful Healing Hearts
GET INVOLVED
Job and Volunteer Opportunities
RMHC MERCH
Ways To Give
Guest Chef Information
EVENTS & NEWS
Golf Tournament
Quarterback SACK
Red Shoe Shindig
Meal & Events Calendar
Newsletters
CONTACT
Family Stories
Search for:
HOME
ABOUT
Ronald McDonald House
Our Relationship with McDonald’s
Family Rooms
Grants and Scholarships
Hopeful Healing Hearts
GET INVOLVED
Job and Volunteer Opportunities
RMHC MERCH
Ways To Give
Guest Chef Information
EVENTS & NEWS
Golf Tournament
Quarterback SACK
Red Shoe Shindig
Meal & Events Calendar
Newsletters
CONTACT
Family Stories
GUEST REGISTRATION
R Westfall
2023-01-24T11:01:51-06:00
GUEST REGISTRATION
Please enable JavaScript in your browser to complete this form.
Patient's Name
*
First
Last
For office purposes.
Requested Check in Date
Please enter
Have you previously stayed at RMHC in other locations?
*
Yes
No
This is strictly for office information and does not affect your stay with us.
Have you previously stayed with us here at RMHC of the Southwest in Lubbock?
*
Yes
No
For office information.
If so, please enter dates here.
*
Please enter MM/YEAR (to the best of your memory) of most recent stay.
Father
*
First
Last
If this section does not apply to your stay with us, simply enter N/A in the fields.
Father's Date of Birth
*
Please enter as MM/DD/YEAR format (ex.: 07/16/2019)
Mother
*
First
Last
If this section does not apply to your stay with us, simply enter N/A in the fields.
Mother's Date of Birth
*
Please enter as MM/DD/YEAR format (ex.: 07/16/2019)
Patient's Name
*
First
Last
Patient's Gender
*
Male
Female
Patient's Date of Birth
*
Please enter as MM/DD/YEAR format (ex.: 07/16/2019)
Patient's Social Security Number
*
If patient is a newborn without an assigned SS#, enter N/A in this field.
Patient's Medicaid #
*
If not yet available, please enter N/A in this field.
Patient's Medicaid Card Upload
Click or drag a file to this area to upload.
If the patient has Medicaid, take a photo of the card and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.
Patient's Name (multiples)
First
Last
If there are multiple patient's, please contact the office to complete your registration by calling 806-744-8877.
Mother's Social Security Number
*
Mother's Medicaid #
*
If you do not have medicaid, please enter N/A in this field.
Mother's Medicaid Card Upload
Click or drag a file to this area to upload.
If the mother has Medicaid, take a photo of the card and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.
Family Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
Primary Contact Phone
*
Contact Email
*
Email is a very easy way for us to stay connected to the families in the House. Please include the email address that you most regularly check.
Work Phone
Employer Name
Emergency Contact Name / Relationship to Patient
*
Emergency Contact Number
*
Automobile Make / Model / Color
*
In the event that your vehicle requires attention while in the RMHC parking lot, we will need your vehicle information. If you will not have a vehicle during your stay with us, enter N/A in this field.
Vehicle License Plate #
*
Enter N/A if no vehicle will be present during your stay at RMHC.
Medical Facility
*
University Medical Center Children's Hospital
Covenant Children's Hospital
Joe Arrington Cancer Center
Trustpoint Rehabilitation Hospital of Lubbock
Other (please leave in notes below)
Other Medical Facility:
Hospital department of admission
*
i.e. Pediatrics, NICU, PICU, etc.
Patient's Hospital Physician
*
Please indicate the name of the doctor overseeing the patient's current hospital stay. If unknown, enter N/A in this field.
Referring Social Worker
*
Bonnie (Joe Arrington)
Millie Ontizeros (UMC NICU)
Chloe Baca (UMC PICU)
Melanie Boyles (UMC)
Jazmin Gonzales (UMC PICU/Pedi)
Whitney Moore (Covenant)
Char Rantz (Covenant)
Joe Vasquez (Joe Arrington)
Griselda (SWCC)
UMC Social Worker (please list workers name below)
UMC Social Worker
Patient's Diagnosis
*
Patient is rooming:
*
in the hospital, as a registered in-patient.
in the hospital on an out-patient basis.
with guardian at RMHC while receiving treatment at a local medical facility.
Number of people staying in RMHC room:
*
Patient's sisters staying in room (include child's age):
*
Enter names/ages separated by commas. (ex.: Jane Doe/8, Mary Doe/3, Sally Doe/1) Enter N/A if this section does not apply to you.
Patient's brothers staying in room (include child's age):
*
Enter names/ages separated by commas. (ex.: John Doe/11, Jim Doe/6, Alex Doe/4) Enter N/A if this section does not apply to you.
Other guests staying in room (i.e. grandma, aunt, uncle, etc.):
*
Enter name / relationship, separate multiple entries by commas (ex.: John Doe / grandfather, Mary Doe, grandmother, etc.) . Enter N/A if this section does not apply to you.
The following data is used only to assist RMHC in obtaining funds for our services and will not play a role in your eligibility status. It is safely collected data which is used for the charities funding purposes only.
*
Please enter total number of family members living in your home in the space above.
Race / Ethnicity
*
Asian
Black / African American
Hispanic / Latino
White / Caucasion
Other
Check all that apply in your household.
Family's total annual income:
*
$0 - $12,000
$12,000 - $15,000
$15,000 - $18,000
$18,000 - $21,000
$21,000 - $24,000
$24,000 - $27,000
$27,000 - $30,000
$30,000 +
Name
Submit