Online Registration

Assigned or Likely to be Assigned Case Worker/Hospital Staff:

Social Worker Name

Social Worker Phone and Extension

Social Worker Email

Patient Information:

* Patient Name ( First and Last )

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

Patient Gender

Patient Ethnicity

* Reason For Stay

* Department

* Briefly explain your child's situation.

* Will the patient be inpatient or outpatient?

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

* Patient is being treated at:

Name of originating or home hospital?

Town of originating or home hospital?

Does anyone in the family have a service animal? While family pets and companion animals are not allowed in the Houses, service animals are welcome.

No Yes

Stay Dates:

* Date of first appointment at hospital

* Preferred Check-in Date

* Expected Check Out Date (If NICU, use due date)

Guardian/Caregiver Information:

Parent/Guardians must be at least 18 years old. If one or both parent/guardians are under 18, you must have a guardian who is over 25 staying at the House. You will be able to enter Mother and Father information along with other guests in the Guests section of this registration process.

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Ethnicity

* Primary Phone Number

I agree to receive texts at this number.

* Guardian Email (type N/A if no email)

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Ethnicity

Primary Phone Number

I agree to receive texts at this number.

Emergency Contact:
Please provide the name and phone numnber of a relative or friend of that patient's family in the event staff cannot get in touch with the patient's family.

* Emergency Contact Name (first and last):

* Emergency Phone:

Family Information:

* Primary Language

Patient's Address
(If family does not have a permeant address, please call 309-401-2525 to discuss).

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

RMHCCI welcomes all families. We celebrate a varity of holidays throughout the year. If you would like to share, what holidays might your family recognize or celebrate while staying with us?

Additional Guests:

Additional Guests / Family Members: Add Another Guest

Vehicle Information:

Family's method of transportation to the hospital or our House (personal car, hospital shuttle, car for hire, etc)?

Will you have a vehicle on premises?

Car Make/Model/Description

Car License State

License Plate#

Additional Information