Online Registration

Welcome

Have you stayed at Ronald McDonald House Charities of the Bluegrass in the past?

Yes No

Have you stayed in the past 6 months?

Patient Information

* Patient Full Name - use the patient's name as listed on the hospital records.

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

Patient Gender

* Patient Ethnicity

Reason For Stay

* Patient is being treated at:

Department

Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

* Date of first appointment at Hospital/Dr. Office

* Check In Date

Check out date if known

Primary Language

Please list the patients physical home address below.

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Guardian Contact Information

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Guardian/Caregiver Gender

* Ethnicity

* Email

* Primary Phone Number

Second Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Guardian/Caregiver Gender

* Ethnicity

* Email

* Primary Phone Number

Additional Guests

Will there be any additional guests at the House throughout your stay? Please enter their information below (siblings, grandparents, aunts, uncles, etc).

Additional Guests / Family Members: * * *

Add Another Guest

Additional Information

* Can all family members (not including infants/toddlers) walk up 14 stairs?

* If No, please provide additional information:

* Is any guest currently enrolled in a drug or alcohol treatment program?

* Does any guest have any prior felony convictions?

* Does any guest have any prior convictions of a violent crime?

* Does any guest have any prior convictions of a crime of a sexual nature?

* Does any guest have any prior convictions of a crime involving a child?

* Emergency / Additional Contact name

Relationship to patient:

* Emergency / Additional Phone

* Will you have a vehicle on premises?

* Car Make/Model/Description

* Car License State

* License Plate#

* Do you have Medicaid Insurance?

* Medicaid Branch

* Medicaid Id (if no medicaid, type N/A)

* Medicaid State:

The 2 following questions are strictly for grant purposes.

* Is any guest a veteran?

* What is the guardians AMI (Annual Median Income)

* How did the family hear about the Ronald McDonald House?

* Do any of the guests have a serious allergy or medical problems that you would like us to be aware of? Such as peanut allergy or seizures – If Yes, please list below.

Guest Policies

These policies are designed to ensure the comfort and safety of our guests. We ask that all guests and visitors conduct themselves in a respectful manner. As a private, non-profit organization, the Ronald McDonald House (RMH) reserves the right to evict guests at our discretion to ensure the safety & well-being of our guests, our volunteers, our staff, and our facility.

Eligibility

The RMH serves as a “home away from home” for families with a patient (21 years and under) receiving inpatient or outpatient medical treatment at an area hospital, clinic, or doctor’s office. First time guests to the RMH must be referred by medical personnel. All guests must be 18 years of age or older unless accompanied by a legal guardian, essential caregiver, or able to provide documentation of marriage or of a court-issued declaration of emancipation. All prospective RMH guests (18 years & older) must submit to a criminal background check before staying at the RMH. Individuals with a felony conviction, a conviction of a violent crime, a conviction of any crime involving a child, or any conviction of a crime that is of a sexual nature will not be granted accommodation at the RMH. Furthermore, any prospective RMH guest who is currently in a drug or alcohol treatment program will not be granted accommodation at the RMH. Finally, any prospective RMH guest who is the subject of a pending child abuse or domestic violence case will not be granted accommodation at the RMH.

Office Hours

The RMH is staffed 24 hours a day, 7 days a week, 365 days a year. House Managers are available from 8:00 AM until 12:00 AM (midnight). A private security firm provides an on-site officer from 12:00 AM (midnight) until 8:00 AM.

Check-In

Guests arriving for check-in must arrive with their photo ID (if 18 or older) and all required paperwork. The check-in process for new guests typically takes about 45 minutes and includes paperwork, a review of RMH policies, and a brief tour of the RMH. We understand that unexpected events occur, but guests are strongly encouraged to check-in between 8:00 AM and 8:00 PM. Guests arriving for check-in between 12:00 AM (midnight) and 8:00 AM will receive a temporary check-in and will need to speak to the House Manager at their first opportunity to finish the check-in process.

Guest Identification

A guest is anyone staying overnight. All guests (18 years & older) must present a photo ID and a referral slip from hospital personnel (for first time guests only) at the time of check-in. Guests will be issued a red ID necklace and are expected to wear and clearly display their red ID necklace at all times while on RMH property.

Room Use

There are to be no more than four people (babies count as a person) per room. Families are expected to use their room every night. Guests must receive authorization from a House Manager if they need to spend a night outside of the RMH (at the hospital, etc.). Any time one guest leaves and any time another guest arrives, they must sign in with the House Manager. “Swapping” guests is not allowed without first speaking to a House Manager. New (first time) guests coming to stay with you must be referred by your medical provider.

Daily Sign-In

There is a sign-in at the front desk. Guests are expected to sign in each day before 8:00 PM. Guests who fail to sign in for two (2) consecutive nights will be checked out of their room and will not be allowed to return to the RMH as a guest.

Admittance

Guests are never to open any door or window for anyone, even if you know the individual seeking access. The RMH is a secure facility, and all visitors must be admitted by authorized staff and volunteers only. Guests may grant entry to their personal visitors only at the front entrance.

Quiet Hours

Quiet hours are from 11:00 PM until 8:00 AM. We ask that you be respectful of your fellow guests and please keep TVs, radios, and voices low during quiet hours.

Hospital Visitation

Guests are expected to visit their patient child every day. This includes all occupants of a guest room unless hospital regulations forbid visitation. This visit should be for an appropriate amount of time as determined by hospital personnel.

Children

Anyone under the age of 18 is considered a child. Parents, legal guardians or guests checked into RMHC and listed on the patient’s referral are responsible for their children. No one under the age of 18 is to be left at the RMH without a parent, legal guardian or adult guest checked into the Ronald McDonald House from the same room. Children under the age of 14 must be in their caregivers’ sight at all times. Although we respect the right of parents or caregivers to discipline their children as they see fit, corporal punishment (including but not limited to spanking) is not allowed on RMH property and will be regarded as abuse. Violation of policy may result in eviction.

Visitors

A visitor is someone who will not be staying overnight. Visitors must sign in with the House Manager as soon as soon as they arrive, present a photo ID, and wear a yellow ID necklace at all times. Visitors should return their yellow ID necklace and sign out at departure. Visiting hours at the RMH are 8:00 AM until 11:00 PM. All visitors must be 18 years of age or older unless accompanied by a legal guardian or able to provide documentation of marriage or of a court-issued declaration of emancipation. We ask that visitors not be left unattended regardless of age.

Parking

Guests are issued a parking pass at the time of check-in. This pass should be clearly displayed (on the dashboard or rearview mirror) when on RMH property. All vehicles on RMH property are expected to be in good running condition and compliant with license, registration, and insurance laws. Repairs to vehicles (other than minor issues such as charging a battery or inflating a tire) may not be performed on RMH property. For safety concerns, guests are not allowed to loiter in their vehicles or in the parking lot.

Emergency Procedures

An evacuation map is posted on the door of your guest room. In the event of an emergency, please follow the evacuation map for your guest room and any instructions issued by RMH staff.

Dress Code

We ask that guests wear appropriate attire for a public setting while at the RMH. For health reasons, shoes or slippers must be worn at all times outside of your guest room.

Tobacco

No tobacco products may be used anywhere inside the RMH. This includes but is not limited to cigarettes, cigars, dip, and snuff. There is a designated smoking area on the porch facing the parking lot where these products may be used. Tobacco products may not be used in the parking lot or on the sidewalks.

* I understand the policies contained above

* Type your Electronic Signature: