RMHC North Central Florida will cover the cost of up to 4 background checks. 
Each additional background check will require a minimum donation of $10.


Patient Information:
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Guest Information:
You may add additional guests to your stay below. But each guest must complete a separate form.
Background Check Information:

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Add Another Guest
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Address:
Please include street address, city, state, county and zip code.
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Social Security #
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Drivers License / State Issued ID #
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By electronicly signing this form, you are affirming that the information you have provided is true and correct to the best of your knowledge; you are giving permission for a security check to be run, including a criminal background; you are consenting to RMHC sharing acquired information with relevant medical facility personnel; and you are agreeing to conform to all policies and regulations as stated in the Guest Rules.
 
Electronic Signature: