Registration Card

* Patient Name ( First and Last )

* Patient Date of Birth (MM/DD/YYYY)

* Patient Ethnicity

* Location of Patient

Patient Room #:

* Parent or Guardian First and Last Name

* Relationship to patient

* Email:

Home Address

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

(Please note that your personal information will not be shared with any other organization. By providing your email, you may receive updates from RMHC)

Make, Model, Color of Vehicle

Within the last week has anyone in your party had a fever, nausea, vomiting, or diarrhea not cause by treatment?

If yes, please explain:

Do you wish to accept personal calls while staying at RMH?

Are you comfortable with the RMH House dog, Archie?

Annual Household Income: