Complete and submit the form below.
If you have any questions, call 701-232-3980.



*
Yes   No

*
*
*
*
* Have you asked your child's doctor's office or social worker at the hospital to send RMHC a referral?
Transportation Needed?
Handicap Accessibility Needed?
*

*

* Number of Adults Staying?
* Number of Children Staying?

Physical Address
U.S. / Canadian Postal Code lookup


*
*
*
*
*
*
*

Please list all guests who will be staying at the House

*

Add Another Guest

Vehicle Information

Off-site Emergency Contact
*
*
Relationship to Patient
Guest Health Screening

Please answer YES or NO to all of the questions below.
* Fever higher than 100.4ºF (38ºC) in the past 72 hours?
Yes No
* Vomiting in the past 2 days?
Yes No
* Stiff neck or headache with a fever in the past 2 days?
Yes No
* Diarrhea in the past 2 days?
Yes No
* Current skin lesions that are "weepy" (fluid or pus-filled)?
Yes No
* ANY current skin rash?
Yes No
* Current cold or flu symptoms (runny nose, cough, congestion)?
Yes No
* Exposure to Tuberculosis (TB) in the past 2 months?
Yes No
* Exposure to any of the following within the past 3 weeks?
Chickenpox
Measles
Mumps
Whooping Cough
No illness listed above
Coronavirus-related Health Questions
* Do you have a fever, chills, sore throat, cough, new onset of shortness of breath, new onset loss of taste or smell, or new onset muscle pain, or have a pending COVID-19 test because you were having any of these symptoms?
Yes No
In the last 14 days, have you been exposed to anyone with a lab confirmed COVID-19 test or have you had a COVID-19 positive test results?
Yes No
* Do you have a pending COVID-19 test without any of the symptoms previously mentioned?
Yes No
* Have you been told by a healthcare provider or public health official that you should self-quarantine due to potential COVID-19 exposure?
Yes No
* I/We consent to a criminal background check: