* Have you stayed with RMHC-KC in the past three (3) years?

* I understand that RMHC-KC cannot guarantee rooms as availability changes on a daily basis. Families should call 816-541-8460 the day of your requested check-in date to see if we have availability.

* The patient receiving evaluation and/or treatment is 21 years of age or younger?

* Do any members of the guest party have symptoms related to contagious illnesses?

* Does anyone in the guest party have a pending child abuse investigation or open CA/N case?

* Does anyone in the guest party have an assault related or sex related crime?

* Does anyone in the guest party have any felony charges or convictions?

Patient Information

* Patient Name ( First and Last )

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

* Patient Vaccination Status

* Patient Gender

Primary Language

* Patient Ethnicity

* Does the patient have Mediciad?

Medicaid Branch

Medicaid Id (if no medicaid, type N/A)

Medicaid if yes, brief description of what patient is being seen for

* Date of first appointment at hospital

* Will the patient be inpatient or outpatient?

* If out-patient: Date of last appointment at hospital (MM/DD/YYYY)

* Department

Diagnosis

* Check In Date

* Check Out Date

* Patient is being treated at:

* Physician/Doctor

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Contact Information

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Guardian 1 Vaccination Status

* Ethnicity

* Email

* Primary Phone Number Primary Phone Number

* Alternate Phone

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Guardian 2 Vaccination Status

Ethnicity

Primary Phone Number

Guests

Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the patient’s family.

* Emergency / Additional Contact name

* Emergency / Additional Phone

Additional Information

Family’s method of transportation to the hospital or our house?

Will you have a vehicle on premises?

Car Make/Model/Description

Car License State

License Plate#

* Has anyone in the guest party been asked to self-quarantine due to COVID-19 in the past 10 days?

* In the last 48 hours, has anyone in the guest party had: cough, shortness of breath, difficulty breathing, new loss of smell/ taste, sore throat, runny nose/ congestion and/or GI symptoms?

* In the last 48 hours, has anyone in the guest party had: a fever of 100.0 degrees fahrenheit or higher, body aches, and/ or headache?

* Is anyone in the guest party waiting on a COVID test result not related to preadmission testing for the patient?

* Has anyone in the guest party had a positive COVID test in the last 10 days?

* Does anyone in the guest party need a wheelchair accessible room?

* Is there any additional information you would like to add?