Go to the RMHC North Central Florida website.
Online Registration
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:
*
Patient Name ( First and Last )
*
Patient Date of Birth (MM/DD/YYYY)
Guest Information:
You may add additional guests to your stay below. But
each guest must complete a separate form
.
Background Check Information:
*
*
*
*
I agree to receive texts at this number.
Add Another Guest
*
Address:
Please include street address, city, state, county and zip code.
*
Social Security #
*
Drivers License / State Issued ID #
*
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:
Help Request Sent
Ok
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
Submit
