Please complete this registration form to become a guest at RMHC.
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Name of Person Completing Form:
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Home hospital/physician:
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Referred by:
Referred by phone: (###-###-####)

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Yes   No

If yes, what year?

Family Information
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Parent 1/Guardian Address:
U.S. / Canadian Postal Code lookup


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To add addiotional Patients, use the Additional Guests/Family Members section below and choose the relationship 'Patient'.
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If Medicaid, which state? (Choose N/A if they do not have Medicaid.)
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Does the patient have Private Insurance?
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If Private Insurance, who is your insurance provider? (type N/A if they do not have private insurance)
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I authorize the RMHC of Toledo to bill Medicaid on my behalf.
Additional Guests / Family Members

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Add Another Guest
No   Yes
Do you have a religious preference?
Do you have any food allergies we should be aware of?
RMHC strives to ensure the physical and emotional comfort and safety of all our guests. Because it is our mission to create a homelike environment, RMHC reserves the right to refuse admittance to anyone who is either currently on probation or parole or has been convicted of any of the following, which includes but is not limited to: (1) a crime of violence, (2) a crime of theft, (3) a crime of domestic violence, (4) a crime against a child and/or an open child protective services case, (5) a crime involving illegal drugs, or (6) a felony of any kind. We also reserve the right to refuse admittance to any one required to register on the Ohio or National Registered Sex Offender Registry. Everyone over the age of 18 wishing to stay at the House must agree to a criminal background check. If you refuse to agree to a criminal background check you will be denied admission to RMHC. BACKGROUND CHECKS WILL BE RUN ON AN ANNUAL BASIS.
For health and safety purposes, as well as to confirm that guest rooms are maintained properly, Ronald McDonald House Charities reserves the right to conduct room inspections. There is no expectation of privacy (RMHC or personal) brought into the house. Two staff members and/or volunteers will conduct room inspections (announced or unannounced) on at least a weekly basis. Additionally, you are responsible for securing your personal property at all times. When away from your assigned room you should not leave cash or other valuables in the room. Guests shall not bring offensive, inappropriate or illegal property onto the premises at any time.
If any violation of House rules is identified, the House reserves the right to require correction within 24 hours or immediately terminate the guest's stay.

It costs over $100 per night, per room, to operate the Ronald McDonald House program. To support the ongoing operations of the House, we encourage, but do not require, guests to make a donation of $10 per night, or whatever they are able, in order to continue the House operations for future guests. However, no family is ever turned away due to their inability to contribute. Please discuss any questions with the Family Services Manager.
CONFIDENTIALITY AND EXCHANGE OF INFORMATION
In order to serve you and other families in the fairest manner possible, the Staff of Ronald McDonald House Charities of Northwest Ohio may find it necessary to obtain and exchange information with care providers. This Information includes medical, social and demographic information that is classified as Protected Health Information (PHI) per the Health Insurance Portability Act of 1996 (HIPAA). These communications are via telephone or fax. These communications are limited to what is necessary to verify there is a clinical need for your family to stay at Ronald McDonald House (RMH) and to help assure that RMHC of NWO is making good decisions regarding utilization of RMH space and resources. This information is also used for the purpose of maintaining a safe environment for guests staying at MH. Your privacy is important to us. Information obtained by RMHC of NWO will not be released to other families staying at RMH, nor will it be sold or exchanged with third parties.
AGREEMENT AND SIGNATURE
By electronically signing this form, you understand and agree that care providers are authorized to provide medical, social and demographic information, for the purposes as described above, to Ronald McDonald House Charities of Northwest Ohio. You certify that you are at least 18 years of age, and you further understand and agree that this Agreement applies to the signer and all members of the signer's family for all current and future visits and stays at the Ronald McDonald House of Northwest Ohio. I agree to abide by all RMHC policies for the duration of my stay. I understand that failure to do so can result in my (and/or family members and guests) removal and future guest privileges revoked. I further accept all responsibility for any damages caused to RMHC (its property and contents) or another individual's (property and contents) by me, my family and/or my guests.
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Electronic Signature 1:
Electronic Signature 2:
Electronic Signature 3: 
Firma Electrónica 4: