* 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.

* Please check the box to acknowledge the above conditions of stay.

Room Use

• RMHC-KC provides one room per patient.
• If anything prevents you from using your room every day, we will ask that you check-out so that your room may be given to the next family on our waitlist.
• Check-out time is 10:00 AM.
  • Failure to check-out on time may jeopardize your eligibility to stay with us in the future.

* Please check the box to acknowledge the above conditions of stay.

Guest/Visitor Safety Screening

• All visitors and guests must check-in at the front desk upon arrival.
• 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).
• A photo ID is required for everyone 18 and older, this includes visitors and guests.
  • All IDs are scanned at arrival.

* Please check the box to acknowledge the above conditions of stay.

Supervision of Children

• Our homes 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 other house guests’ children.

* Please check the box to acknowledge the above conditions of stay.

Infectious Disease

• To protect the health and safety of everyone on campus, all guests and visitors must be sympto-free of any contagious illness.
• If during your stay, anyone in your guest party has any symptom(s) of contagious illness (cough, fever, rash) please notify staff immediately.
  • If anyone tests positive for COVID-19 or has symptoms of ANY 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.

* Please check the box to acknowledge the above conditions of stay.

Physical Safety

• Alcohol, marijuana, illegal substances, and weapons are strictly prohibited on our property.
• Please use the designated smoking areas located outside each house.
  • Smoking and vaping are not allowed inside any of our rooms or 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 safekeeping of guests' personal property.
  • Any abandoned property will be donated.
• We reserve the right to enter your room for the health and safety of all RMHC-KC guests.
  • We may need to enter your room for emergencies, maintenance work, and/or routine room checks.
• To help identify RMHC-KC guests, we ask that anyone over 12 years of age wear a wristband.
• All guests must wear shoes outside of their rooms.

* Please check the box to acknowledge the above conditions of stay.

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.

* Please check the box to acknowledge the above conditions of stay.

Service Animals

• Service animals that are individually trained to work or perform specific tasks for the benefit of an individual are welcome here.
  • A signed Service Animal agreement must be on file.

* Please check the box to acknowledge the above conditions of stay.

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?

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

* Please type your Electronic Signature Here:

* Primary Phone Number

* Today's Date:

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.