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



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Yes   No

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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?
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Number of Adults Staying?
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Number of Children Staying?

Physical Address
U.S. / Canadian Postal Code lookup


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Please list all guests who will be staying at the House

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Add Another Guest

Vehicle Information

Off-site Emergency Contact
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Relationship to Patient
Guest Health Screening

Please answer YES or NO to all of the questions below.
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Fever higher than 100.4ºF (38ºC) in the past 72 hours?
Yes No
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Vomiting in the past 2 days?
Yes No
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Stiff neck or headache with a fever in the past 2 days?
Yes No
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Diarrhea in the past 2 days?
Yes No
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Current skin lesions that are "weepy" (fluid or pus-filled)?
Yes No
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ANY current skin rash?
Yes No
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Current cold or flu symptoms (runny nose, cough, congestion)?
Yes No
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Exposure to Tuberculosis (TB) in the past 2 months?
Yes No
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Exposure to any of the following within the past 3 weeks?
Chickenpox
Measles
Mumps
Whooping Cough
No illness listed above
Coronavirus-related Health Questions
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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
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Do you have a pending COVID-19 test without any of the symptoms previously mentioned?
Yes No
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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
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