Patient Name ( First and Last )

Patient Date of Birth (MM/DD/YYYY)

* Cultural and Psychological Safety: RMHC-KC is committed to providing an inclusive and safe environment for everyone. All people on our properties (guest families, visitors, volunteers, staff, vendors, and donors) are expected to act with respect and kindness to all other people at RMHC-KC at all times. Every person is welcome here, disrespectful and unkind behaviors are not. Guests are responsible for their visitors and the behavior of everyone in their guest party. 

* Room Use: RMHC-KC provides one room per patient. If anything prevents you from using your room on a daily, we will request that you check-out so that your room may be given to the next family on our waitlist. You will be provided lodging, again, when needed.

* Guest/Visitor Safety Screening: A photo ID is required for everyone 18 and older. IDs will be scanned at arrival and run through the National Sex Offender Registry. All guests must be free of felony convictions (some felonies may be eligible for exception). All guests must be clear of any crimes or misdemeanors related to assault, sexual offenses, or crimes against children and may not have a pending child abuse investigation or open child abuse/neglect case (no exceptions).  

* Supervision: Our houses have many fun places for your child to explore. For their safety, children under 12 years old must be supervised by an adult at all times. Any child under 18 years old cannot be left alone at RMHC-KC at any time. This includes siblings and visitors. Staff, volunteers, and other RMHC-KC guests’ cannot provide childcare for any other house guests’ children.

* Infectious Disease: If anyone in your party has symptoms of any contagious illness, please notify staff immediately.

* If anyone in your guest party tests positive for COVID-19 or has symptoms of contagious illness, that person needs to check out immediately and remain off campus for five days. (Day zero is the first date of symptoms or a positive test.) Based on family need/situation, RMHC-KC may provide hotel lodging.

* Physical Safety: Alcohol, marijuana, illegal substances, and weapons are strictly prohibited on our property. Smoking and vaping are not allowed inside any of our buildings and is cause for immediate removal and loss of future eligibility.
● RMHC-KC is not liable for loss, theft, or damage of any personal property. RMHC-KC is not responsible for the safe keeping of guests' personal property. Any abandoned property will be donated.
● On occasion and every 30 days, we may need to enter your room for emergency/maintenance work and/or routine room checks. We reserve the right to enter your room for the health and safety of all RMHC-KC guests.
● To help identify RMHC-KC guests, we ask that anyone over the age of 12 wear a security wristband.
● All guests must wear shoes when they are outside of their room.  

* Family Friendly: Our environment is child- and family-friendly at all times. We do not tolerate any acts of violence, nor do we allow disruptive or threatening words or behaviors. RMHC-KC is also a “hit-free zone.” Child abuse and/or physical punishment (like spanking) will not be tolerated. These actions will result in immediate dismissal from the house. We reserve the right to ask any guest to check out at any time.

* Engagement: Our programs are designed to keep families close to their seriously ill children. It is our expectation that, whenever possible/reasonable, families are actively engaged in their patient’s care.

* Permissions:
● In some instances, RMHC-KC may need to contact your medical team about your stay at the house. Do you grant RMHC-KC staff permission?

* Permissions:
● Do you give staff/volunteers permission to forward incoming calls to your room?

* Support Animals: Service animals that are individually trained to work or perform specific tasks for the benefit of an individual are welcome here.

Note: By receiving this document and checking in to RMHC-KC, you understand that you and the members of your guest party must adhere to the “Conditions of Stay” listed above, and failure to comply may result in loss of eligibility.

* Please type your Electronic Signature Here:

* Primary Phone Number

* Today's Date: