RMHC CHECK-IN FORMS

GUEST REGISTRATION

Patient's Name *

First

Last

For office purposes.

Requested Check in Date

Please enter

Have you previously stayed at RMHC in other locations? *

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? *

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

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 *

Other Medical Facility:

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.

Hospital department of admission *

i.e. Pediatrics, NICU, PICU, etc.

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: *

Comment

BACKGROUND CHECK CONSENT

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 *

Click or drag a file to this area to upload.

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 *

Click or drag a file to this area to upload.

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 *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

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.

Signature

Dated: *

Please enter date

Phone

COVID-19 PROTOCOLS

Patient's Name *

First

Last

For office purposes.

Checking the protocols listed below indicates your acknowledgement of these protective measures and your family's agreement to uphold them throughout your stay at RMHC *

Social distancing should be practiced when in the presence of non-family members.
Common areas (basement, playroom, living room) are temporarily closed.
Only one family at a time may be in both the laundry room and the kitchen.
Masks are required to be worn in all areas of the House outside of your private guest room.
Temperatures will be checked and logged on every person entering the House, upon each entry.
You are asked to eat either in your room or at your pre-assigned dining room table. Please dispose of any leftover food and plates in the KITCHEN trash.
If you feel ill, please report your symptoms to the House Manager or the Manager on Duty.

SYMPTOMS TO REPORT INCLUDE: *Fever higher than 99.5 F / 37.5 C *New cough or worsened chronic cough *New loss of sense of smell or taste *Upper respiratory symptoms (e.g. shortness of breath) *GI symptoms (e.g. nausea, vomiting, diarrhea) *Headache *Body aches *Fatigue

COVID-19 SCREENING QUESTIONS

Have you had any history of fever in the last 14 days? *

Have you had any respiratory illness such as cough or difficulty breathing in the last 14 days? *

In the past 14 days, have you or any household member had any contact with a known COVID-19 patient? *

Have you or any household member traveled to areas of suspected community spread in the last 14 days? *

Have you or any household member been tested for COVID-19 in the past 14 days? *

Are you experiencing a loss of sense of smell or taste? *

Lodging at the Ronald McDonald House is a privilege and not a right. All guests are expected to abide by the rules of the Ronald McDonald House AND to act responsibly and respectfully in all instances, which may not be outlined in this document. Failure to do so may result in being required to immediately vacate the House based on the discretion of management. (copy)

I have read and understood the COVID-19 Protocols.
I acknowledge these rules and will abide by them during my stay at the Ronald McDonald House.

Signature

Date signed:

Please enter in MM/DD/YEAR format (ex.: 08/14/2020)

Comment

GUEST RULES AND AGREEMENT

Patient's Name: *

First

Last

For office purposes.

Parent's Name *

First

Last

For office purposes.

Checking each of the House 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 Ronald McDonald House.
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 office of the departure or arrival of any guest or visitor staying in the room.
8. RMHC has the right to limit the number of registered guests per room.
9. Registered guests are limited to immediate family members or primary care-givers of the patient.
10. All registered guests and visitors must wear the appropriate wrist band (assigned upon arrival).
11. Callers who ask for a registered guest by name will be transferred to that guest's phone extension. Visitors who come to see a registered guest must be met in the lobby.
12. Children under the age of 15 must be supervised by a parent or guardian at all times.
13. People exposed to or having contagious illnesses may be required to vacate the House. Guests who have been diagnosed with a contagious illness must notify the office immediately.
14. Guests are required to cooperate fully with the staff in providing information and assistance required to obtain third-party reimbursement, (i.e., Medicaid).
15. Loud or disruptive behavior is not allowed at any time. Quiet hours are from 10:00 PM to 7:00 AM.
16. 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.
17. 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.
18. No animals, except service animals, are allowed on RMHC property.
19. Management of RMHC has the right to make random room checks at their sole discretion.
20. Access to each guest room is mandatory for daily cleaning (sweeping and trash collection), to be performed by a member of the RMHC staff.
21. A transportation schedule will be made available in the office and it is your responsibility to check and follow it.
22. If my child is not in Intensive Care, I understand that I may be asked to vacate my room in the event that the House is full and other families of critically ill children need lodging.
23. After 30 days, RMHC reserves the right to review House occupancy, the family's adhereence to House rules and policies, and other factors deemed relevant in order to authorize or decline additional nights.

Lodging at the Ronald McDonald House is a privilege and not a right. All guests are expected to abide by the rules of the Ronald McDonald House 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 House based on the discretion of management. *

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? *

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

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

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? *

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

Any person who declines a background check will be limited to common areas only and designated visitation times (8:00 AM - 8:00 PM). They must check in to the front office, sing in, wear a visitor band and be accompanied by a registered guest at all times. *

I swear that the information provided on this form is true and correct to the best of my knowledge.

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 the Ronald McDonald House or medical institution, 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, web site/social media, and printed media.
Do not use photographs and videos for publicity, promotional materials, web site/social media, fundraising proposals, or printed media.

Signature *

Date Signed: *

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