Spokane

* Who is completing this registration:
* Have you stayed with us before?
Preferred language if not English?

Who are you caring for?
Patient Information:
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Does the patient or guardian have state insurance?
If the family has private insurance, please add the provider and # if possible.
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

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Who will be staying at RMHC INW?
Parent/Guardian Information:
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U.S. / Canadian Postal Code lookup


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2nd Parent/Guardian Information:
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Additional Guests / Family Members

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Add Another Guest
When can we expect you?
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Special accommodations or other information we should know? (ex: hearing impaired, ADA accessibility required, etc.)