Guest Check in Paperwork


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Background Information
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1. Is any Guest currently enrolled in a drug or alcohol treatment program?
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2. Does any Guest have prior felony convictions?
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3. Does any Guest have any prior convictions of a violent crime ?
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4. Does any Guest have any prior convictions of a crime of sexual nature?
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5. Does any guest have any prior convictions of a crime involving a child?

Contagious Disease Advisory and Questionnaire

Some of the children staying at the RMHC Charleston are treated for life-treating conditions and are unable to fight off common
illnesses. An outside source of infection brought into the House is a serious risk to an already ill child. It is our policy that no one
with a contagious disease may stay the House. We may require further information and evaluation before your stay can be granted.
Please report to a staff person if you or anyone in your family may develop an illness.

Notify Guest Services if any the following list of illnesses has been experienced in the last 14 days.
  
Measles - any type          Mumps          Head/Body Lice          Tuberculosis                 Colds/Flu            Viral or Bacterial infection
Scabies Infectious           Hepatitis       Diarrhea                         Scabies Infectious        Meningitis             Whooping Cough/Pertussis
              
Are you OR anyone you are in close contact with currently experiencing ANY of the following symptoms in the past 14 days?
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Fever (greater than 37.78°C or 100.0°F)
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Severe headache
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Diarrhea/Vomiting/Abdominal Pain
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Respiratory illness
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New or worsening cough
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Sore throat

Conditions-of-Stay

These policies are designed to ensure the comfort and safety of our guests. We ask that all guests, conduct themselves in respectful manner.

As a private, non-profit organization, RMHC Charleston reserves the right to refuse and evict guests, at our discretion, to ensure the safety & well-being of
our guests, our volunteers, our staff and our facility.
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Children under 18 must be always supervised by their own parents/guardians. Corporal punishment of children is not allowed. Adults must supervise children while in common areas. Staff, Volunteers, nor other guests, may supervise children of other guests.
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Guests should NOT enter a room assigned to another guest. Sleeping is not permitted in the common areas.
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Anyone using a room at the RMHC Charleston must be actively and consistently involved in the patient’s care. If the medical professionals deems the need for RMHC Charleston has ended, check out is required.
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Do not let trash accumulate in room. Please remove food trash daily. Report all maintenance issues. Room checks are performed weekly.
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Smoking of any kind, including the use of such things as e-cigarettes & vaporizers is not allowed on property. This includes the House, all porches, Jonathan Lucas Park, Barbara Bond alley, and parking lots.
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No alcohol, illegal drugs, firearms, or weapons allowed on property. All guests must leave their firearms at home or locked in vehicles .
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House staff reserve the right to perform random room inspections for general maintenance issues, or in situations where it is deemed necessary for the overall safety of the House. Guests do not need to be present when inspections are performed.
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Guests are responsible for cleaning their own rooms and for cleaning up after themselves in common areas and in bathrooms. Please ask Guest Services for a container to properly dispose of needles or other infectious materials. The poop from diapers should be flushed in the toilet. The diaper must to sealed in a plastic bag and carried out the dumpster. Appropriate clothing and shoes or slippers are required in common areas.
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RMHC Charleston is not responsible for any personal belongings, or mail and items left. All rights are waived to make a claim against RMHC Charleston in the event of damage, theft or loss of property.
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If a patient or parent is a minor, their partner may not stay in House, whether or not the partner is a minor.
All members of the family must attest to 1) having no current drug/alcohol abuse, 2) having no conviction relating to domestic violence or crimes against children, including status as a registered sex offender; and (3) having no open case or conviction with the South Carolina Department of Social Services or other state’s comparable department.
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Rooms vacated from use for more than 24 hrs without approval of the Guest Services Office is not permitted.
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Only registered guests are permitted to have door Codes. Door codes cannot be shared. Sharing of door codes is grounds for removal. Visitors must be registered with the Guest Services and present a valid ID. A registered guest must greet all visitors. Visitors are not permitted on property past 9pm or before 7am. Strangers are not permitted in the House.
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Staying at the RMHC Charleston is a privilege, not a right. Anyone behaving in a disrespectful, abusive, intrusive, irresponsible, or harmful way will be asked to leave. I understand the House policies and guidelines and accept the responsibility of making sure that everyone staying in the room assigned to my family or my visitors are made aware of them. On behalf of my family and any guest sign below stating our agreement to follow these es and guidelines.

Ronald McDonald House Charities® (RMHC®) Grant, Assignment, Release, and Waiver

I hereby grant to (i) Ronald McDonald House Charities, its affiliates, subsidiaries, franchises, advertising and promotional agencies, and their
respective agents and representatives, any of its Chapter organizations (defined as an entity having the right to use Ronald McDonald House Charities,
Ronald McDonald House, Ronald McDonald Family Room, and/or Ronald McDonald Care Mobile, or other trademarks for charitable purposes)
(collectively, “RMHC”) and (ii) all of RMHC corporate partners (collectively, the “Partners”), including, but not limited to, McDonald’s Corporation, its
affiliates, subsidiaries, franchises, advertising and promotional agencies, and their respective agents and representatives (collectively, “McDonald’s”,
and together with RMHC and the Partners, the “Grantees”), the irrevocable, unrestricted worldwide right to use, publish, display, broadcast, edit,
modify and distribute materials bearing my name, voice, image, likeness and/or any other identifiable representation of myself (collectively, “My
Likeness”.) These materials may appear in any form, style, color, or medium whatsoever now known or later developed (including, without limitation,
photographs, videotapes, films, sound recordings, software, drawings, prints, broadcast, internet and electronic media.) The Grantee’s use of My
Likeness will be limited to use involving raising awareness of or for support of RMHC.I agree that all materials containing My Likeness (including,
without limitation, all negatives, plates and masters of any photographs, files, prints or tapes) shall be and remain the sole and exclusive property of
the Grantees, and I hereby assign any right I may have acquired in or to such material to the Grantees. I hereby release and forever discharge the
Grantees from any and all claims, liabilities and damages relating to the use of My Likeness. I hereby waive any right I may have to inspect or approve
the finished materials or any part or element thereof that incorporates My Likeness.
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I have read and agree to the photo, video and audio consent section above.
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I represent that I am a parent or legal guardian of the person(s) identified above, who is/are a minor(s). I consent to the use of his/her name, voice, likeness and/or other identifiable representation of him/her as set forth above.

Consent to release of information and authorization: To: MUSC, Medicaid, DHEC and/or other provider related to your stay.
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I hereby authorize the above-named medical source to disclose information to the Ronald McDonald House Charities of Charleston guest services staff that is relevant to my/my child’s stay at RMHC Charleston. This information may include relevant medical, psychological, or social issues or concerns, written or verbal, regarding the treatment, hospitalization, or outpatient care of my child. I understand that RMHC Charleston is not a treatment facility and does not maintain records of a confidential nature.

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I also hereby authorize Ronald McDonald House Charities of Charleston to disclose the information provided to the State of South Carolina Department of Health and Human Services (SC DHEC). This information is used to determine eligibility and approval for Medicaid lodging/travel benefits for the period beginning with my arrival date at RMHC and through my confirmed departure date. I hereby authorize and direct Medicaid to issue payment directly to Ronald McDonald House Charities of Charleston of the billed amount for lodging/travel services rendered.


RMHC Charleston Communications 
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RMHC Charleston uses text messaging. The types of messages include emergency alerts, meal updates, general notifications, and/or reminders. By opting in to our texting services, you understand that data rates may apply. You may also opt out at any time by texting the word STOP to our texting number (866) 863-0190
Stay in touch and hear RMHC Charleston updates after your stay!
Please let us know how we may contact you to send updates, newsletters, and opportunities to get involved:
E-mail
Mailing
Text Messages
By selecting, you are permitting RMHC Charleston to contact you in that way.


Parking Information:
 
We understand that Ronald McDonald House Charities of Charleston does not provide any parking.
*Please note that you run the risk of being towed or ticketed if you do not adhere to parking regulations as
outlined by RMHC Charleston, the City of Charleston, and MUSC Parking Management.

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By typing my name below, I affirm my intent to sign this document electronically. I agree that my electronic signature is legally valid and binding, and has the same legal effect as if I had signed by hand.