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PATIENT INFORMATION

To add additional patient(s), enter the information in the additional guest’s section below and select the ‘patient’ relationship.
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Please respond I agree  to each guideline
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I understand that Ronald McDonald House Louisville has the right to enter any guest room. Random room checks will be performed.
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**For continued eligibility, the patient must have a continuum of weekly medical care with a minimum of 3 visits per week with separate dates of service.
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Do you understand a minimum of 4 to 6 hours must be spent at the hospital and you must use your room daily?
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**Guest rooms must be used on a daily basis. Guests with repeated non-use of room within a 24-hour period may forfeit their continued stay with Ronald McDonald House Louisville.
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Zero Tolerance Leading to Immediate Eviction

  • Smoking anywhere inside the House or in other restricted areas.
  • Possession of alcohol, illegal drugs, or weapons, including concealed, on House property.
  • Room abandonment.
  • Physical aggression or any unwanted physical contact toward staff, guests, volunteers, or visitors is strictly prohibited.
  • Violation of a Final Warning.
  • Being under the influence of alcohol and/or drugs.
  • Theft from Ronald McDonald House Louisville or any family.
  • Changing your permanent address to Ronald McDonald House Louisville
  • Violating Ronald McDonald House Louisville's Code of Conduct

Room Policy

  • One room is provided per family, with a maximum of six people, including babies.
  • Registered guests are expected to use the room each night. Exceptions may be made for one night only (24 hours) but must be approved by Family Services staff before leaving the House.
  • When the child is discharged from the hospital or clinic, the family is expected to check out.
  • Anyone 16 years of age or older must wear an Ronald McDonald House Louisville wristband for the duration of their stay.
  • Guest families are NOT allowed to visit another guest’s room. If you want to visit with other guests staying at the House, we ask that you use the common areas of the House, like the play areas, dining room, and living rooms.

Smoking

  • Smoking, vaping, and the use of tobacco products or marijuana are prohibited inside the House.
  • Smoking is prohibited within 50 feet of any entrance/exit or near the playground. This includes the steps on the backside of our building.
  • Smoking is only allowed outside the gate in the ADA parking lot on Chestnut Street.

Recent Exposure to Contagious Disease

  • We ask that guests with recent exposure (within the past 14 days) to an illness considered contagious (i.e., COVID-19, monkeypox, measles, flu, strep, scabies, chickenpox, head lice, hepatitis, mumps, tuberculosis, mononucleosis, bacterial meningitis, etc.) wear a mask when outside of your guestroom.
  • If you have been exposed to a contagious disease or start feeling poorly during your stay, please notify the Family Services staff at the Front Desk right away.

Security

  • Family Services staff are available 24/7 to assist families with making their stay as comfortable as possible. 
  • Security and Family Services Staff are responsible for enforcing House Rules; disrespect towards others (staff, guests, and volunteers) will not be tolerated.
  • Your room key gets you into the House from 6 am - 10 pm. If you need to enter the House outside those hours, you must provide your room number and last name to be buzzed in.

Code of Conduct

We believe everyone deserves the chance to stay, work, and volunteer in an environment that is safe and free from intimidation, hostility, racism, and white supremacist behaviors.

Our staff, volunteers, and guest families deserve kindness and respect, and all will be held to the same high standards of conduct.

Ronald McDonald House Louisville does not tolerate harassment of our staff, volunteers, or guest families in any form.

Anyone who fails to comply with these expectations will be asked to leave the House.

 Children

  • Anyone 16 or younger must always have an adult family member with them. No Hit Zone
  • Our House is a "No Hit Zone." No person shall hit another person ever.

Quiet Hours

  • Quiet hours are from 10 pm-9 am daily.
  • You'll notice some lights will dim at night. You can still use the common spaces, but please be courteous of others who may be getting some much-needed rest.

Receiving Mail

  • You are allowed to receive mail and packages at Ronald McDonald House Louisville. Mail should be addressed to Ronald McDonald House, c/o Your Name, Room #.

Visitors

  • Visitors are welcome from 9 am to 9 pm daily.
  • Please sign in visitors at the Front Desk and LobbyGuard during each visit.
  • Visitors should only visit the main level of our House.
  • You should stay with your guests during their visit in the designated visiting areas only.
  • You are responsible for the behavior and conduct of individuals visiting you.
  • All House rules and codes of conduct apply to visitors.

Parking Lots

  • The parking lot on 1st Street is for all guests.
  • The rear parking lot on Chestnut Street is for guests requiring accessible parking, Ronald McDonald House staff, and volunteers. Only one car per family is permitted in the Chestnut lot due to limited space.

Dress Code

  • All Houseguests should always wear shoes or slippers, along with appropriate clothing, when outside their rooms.
  • Appropriate clothing includes shoes, shirt, pants, dress, adequate coverage.
  • Clothing or visible tattoos should be without offensive language or inappropriate designs.

Check-Out

  • Please check out before 11 am.
  • Follow the checkout procedures listed on our app. You can also request a copy from the Front Desk. Allow at least 30 minutes to complete the process.
  • Guests who leave without checking out properly may be ineligible to return.
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Day Visitors restricted to main level (Private intake room, Dining Area, Front Lobby, Play room)
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Notify Front Desk if you experience symptoms that could potentially be a contagious disease.
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Please confirm that you understand if your stay exceeds 30 days you will be required to allow housekeeping to perform a deep clean of your current room.  
Transportation Waiver
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I understand and acknowledge that the Ronald McDonald House Parties may arrange for transportation by one or more third parties for the Guest Parties in connection with their stay at the House. I, for myself, and for the other Guest Parties, acknowledge and agree that such transportation is arranged as a courtesy, and none of the Ronald McDonald House Parties is responsible for or has any liability in connection with such transportation, and all such responsibility and liability shall be with the third party transportation provider. I, for myself, and for the other Guest Parties, hereby waive and release all Claims against the Ronald McDonald House Parties related to such transportation, and agree to save and hold the Ronald McDonald House Parties harmless from all Claims related to such transportation.

Public Sex Offender Check
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Please confirm you understand Ronald McDonald House Louisville will conduct a formal public sex offender check for all individuals 18 years of age or older. This measure is to ensure the safety and security of all families, which is of utmost importance to us. Persons who appear on the national sex offender registry will be denied lodging.

Temporary Lodging Notice
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Please confirm you understand that you, the Guest, are receiving temporary lodging at a private, non-profit institution, that such residence is incidental to the provision of medical or similar services to a child of Guest, that such temporary lodging is similar to a hotel room, and that Guest does not have a right to exclusive possession of the room(s) Guest is assigned by Ronald McDonald House Louisville. Guest further acknowledges that this is not a rental agreement as defined by KRS 385.545(11), nor is Guest considered a tenant for purposes of the Kentucky Landlord Tenant Act or other applicable law.

Liability Waiver
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Ronald McDonald House Louisville is NOT responsible for personal injury, medical care or loss of personal property. My signature below acknowledges the preceding and the agreement to abide by all House rules contained in the Guest Guidelines that I received at check in. Also, Ronald McDonald House incorporates by reference in this registration form the document titled, “Authorization to Release Protected Health Care Information.”
Photo Release
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As a guest family of Ronald McDonald House Louisville, I understand that photos and/or video recordings may be taken during our stay.

I understand that I may see staff or authorized partners taking photos or videos within the House. Ronald McDonald House Louisville will make every effort to respect each family’s preferences and avoid including individuals who have not given permission. If I have concerns or prefer not to be included, I understand that I can notify staff at any time.


Childcare Contingency Policy
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This acknowledgment confirms that the undersigned guest understands and agrees to Ronald McDonald House Louisville’s Childcare Contingency Policy and related expectations concerning supervision of minor children.
 
Guest Family Understanding and Agreement By signing below, I acknowledge and agree to the following:
  1. No Childcare Services Provided I understand that Ronald McDonald House Louisville is not a childcare provider. Staff members, volunteers, contractors, and other guest families are not permitted to supervise, babysit, transport, or assume responsibility for my child(ren).
  2. Responsibility for Supervision o I understand that I am solely responsible for arranging appropriate supervision for my child(ren) at all times.
    1. I agree that my child(ren) will not be left unattended within Ronald McDonald House Louisville or on its grounds.
  3. Medical Emergencies or Hospitalization If I require medical care and do not have childcare arrangements:
    1. I understand that I must bring my child(ren) with me to the hospital when medically permitted.
    2. I understand that hospital social workers may be contacted to assist with temporary arrangements.
    3. I authorize Ronald McDonald House Louisville staff to contact my listed emergency contacts, if needed.
    4. I understand that if no authorized caregiver can be reached and my child cannot safely remain with me, appropriate child welfare authorities (including CPS or law enforcement) may be contacted as a last resort to ensure my child(ren)’s safety.
  4. Emergency Contacts
    1. I agree to provide at least three current emergency contacts and to update this information immediately on my Emergency Action Plan form if it changes.
  5. Custody Information
    1. I affirm that I have disclosed accurate and complete custody/ guardianship information to Ronald McDonald House Louisville.
    2. I understand that providing false or incomplete information may result in termination of my stay at Ronald McDonald House Louisville.
  6. Authorization to Release Information in Emergencies In the event of a medical emergency involving me or my child(ren), I authorize Ronald McDonald House Louisville staff to: 
    1. Share necessary contact information with hospital personnel or social services solely for the purpose of ensuring my child’s safety.
    2. Communicate with my listed emergency contacts regarding my medical emergency and childcare needs. This authorization is limited to emergency situations involving the safety of my child(ren).
  7. Acknowledgment of Understanding
    1. I have read this document (or had it read to me).
    2. I understand its contents.
    3. I have had the opportunity to ask questions.
    4. I agree to comply with this policy as a condition of my stay.
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Guardian 1 Electronic Signature: