Go to the Ronald McDonald House Charities of Kentuckiana website.
Referral
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Please confirm you understand Ronald McDonald House Charities of Kentuckiana 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.
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I understand
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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 RMHCK. 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.
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I understand
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Have you stayed at RMHC Kentuckiana in the last 30 days?
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No
Yes
Please complete the full application form.
Click Here to go to the full application form.
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Patient Name ( First and Last )
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Patient Date of Birth (MM/DD/YYYY)
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Primary Phone Number
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Date of first appointment at hospital
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Check In Date
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Check Out Date
Help Request Sent
Ok
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
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