Stay Request-MUSC Social Workers

Guest Stay Request MUSC SW

1. Stay Request

* Arrival Date

* Estimated Departure Date

# Occupants First Night

* Request Completed By

* Social Worker

2. Patient Information

* Patient Name (First, Middle and Last)

* Patient Gender

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

* Patient Ethnicity

* Diagnosis

* Facility Treated At

* Will the patient be inpatient or outpatient?

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

* MUSC Hospital Unit

* Insurance Type

Patient Medicaid #

Does the Medicaid Belong to the Patient or the Parent?

Is the home address the address on file with Mediciad? If not, please enter in the feild below.

3. Guest Information

We ask that all guests conduct themselves in a respectful manner. As a private, non-profit organization, RMHC Charleston reservest 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.

* Guardian/Caregiver Name

* Guardian/Caregiver Gender

* Guardian/Caregiver Date of Birth

* Guardian/Caregiver Relationship

* Guardian/Caregiver Email

Guardian/Caregiver Home Phone

I agree to receive texts at this number.

* Guardian/Caregiver Mobile Phone

I agree to receive texts at this number.

Guardian/Caregiver Home Address

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

2nd Guardian/Caregiver Name (First, Middle and Last)

Relationship to patient

2nd Guardian/Caregiver Gender

2nd Guardian/Caregiver DOB

2nd Guardian/Caregiver Email

(must be different from 1st Guardian's email address)

2nd Guardian/Caregiver Mobile Phone

I agree to receive texts at this number.

(must be different from 1st Guardian's phone number)

Is 2nd Guardian/Caregiver's address the same as 1st Guardian?

2nd Guardian Address (if differnt from 1st guardian):

Additional Guests / Family Members: I agree to receive texts at this number.

Add Another Guest

4. Additional Information

Does the family have siblings in town with them? Does the family have any special needs?

Notes Regarding this Request:

Your request will be processed, and we will keep you informed about our availability. Please be advised we generally have long waiting lists.
To stay at our House, families must have a child (18 years or younger) who is receiving medical care in the Greater Charleston area.
Although families are asked to make a donation per night while staying with us, no family is ever turned away due to inability to contribute.

All members of the guest family must meet the RMHC Charleston requirements including:

Please prepare to sign our Conditions-of-Stay Document. For your reference, copies of our pre-registration packets and Conditions-of-Stay Document are available on our website.
We are not permitted to accept family members who may be contagious of an infectious disease.
All member 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 states comparable department.