Day Program

Ronald McDonald House of the Greater Hudson Valley

Families are eligible to use programs if their patient is 21 years of age or younger.

* Patient Name ( First and Last )

* Patient Gender

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

* Patient Ethnicity

* Diagnosis/Reason for Hospitalization

* Patient is being treated at:

* Assigned Social Worker / Hospital Staff

* Department

Neighborhood? (If located in general pediatrics at MFCH.)

Room Number (If unknown, type N/A)

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Primary Language

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

* Email

* Primary Phone Number

I agree to receive texts at this number.

* Household Income

Second Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Email

* Primary Phone Number

I agree to receive texts at this number.

Who else will be joining you to use the Day Program?

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

Add Another Guest

Does your family rely on public transportation?

Does the patient or any member of the family have an infectious disease?

Does your family have an open Child Protective Services (CPS) case?

I authorize the hospital to release information as stated from my child's patient health information record to RMHGHV. I understand I can cancel this authorization at any time by writing to the Ronald McDonald House of Greater Hudson Valley, however, I would then be ineligible for the continuation of RMHGHV services. I understand that once the information has been released according to the terms of this authorization, this information cannot be recalled. Any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by confidentiality laws.

RMHGHV reserves the right to refuse admittance to any person convicted of any other matters that RMHGHV believes, in its sole discretion, has the potential to put the safety and health of guests at risk. Determinations regarding program services/employment/volunteerism for individuals with criminal convictions will be performed using an individualized assessment and in compliance with the necessary laws.

Background checks must be conducted on any guest applicant over the age of 18. By agreeing to these terms, you understand that acceptance or continuation of RMHGHV services are contingent upon results of a background check. Individuals that refuse to complete a background check are not eligible for admittance.