Online Registration
Please complete this registration form to become a guest at RMHC.
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Name of Person Completing Form:
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Date Room Needed:
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Home hospital/physician:
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Referred by:
Referred by phone: (###-###-####)
Your Email Address if you would like a copy of this form.
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Have you stayed or been a day guest at this Ronald McDonald House before?
Yes  
No
If yes, what year?
Family Information
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Parent 1/Guardian Legal Name:
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Relationship to patient:
Patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
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Date of Birth (MM/DD/YYYY)
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Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
Parent 1/Guardian Address:
U.S. / Canadian Postal Code lookup
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Country
--Select--
USA
Afghanistan
Aland
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos [Keeling] Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar [Burma]
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Minor Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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Address
City/Villa/Town
County/District
State/Province
State/Province
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
Zip
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Guardian Phone (###-###-####)
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Email
Parent 2/Guardian Legal Name:
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Relationship to patient:
Patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
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Date of Birth (MM/DD/YYYY)
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Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
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Primary Phone Number
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Email
To add addiotional Patients, use the Additional Guests/Family Members section below and choose the relationship 'Patient'.
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Patient Name ( First and Last )
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Patient Date of Birth (MM/DD/YYYY)
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Patient Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
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Patient Gender
Male
Female
Nonconforming
Unborn
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Medical Facility:
Center for Eating Disorders
Nationwide Children's/Mercy
Outpatient Doctors Appointment
Toledo Childrens
UTMC
Other
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Department
Bone Marrow Transplantation Immune Deficiency
Bronchology
Cardiology
Child and Adolescent Psychiatry
Colorectal
Coronary Care Unit
Craniofacial Center
Cystic Fibrosis
Dermatology
Developmental and Behavioral
Down Syndrome
Ear Nose and Throat
Emergency Department
Endocrinology
Eosinophilic Disorders
Fetal Care Center
Gastroenterology
Genetics
Gynecology
Heart Transplant
Hematology
ICU
Kidney Transplant
Liver Transplant
Liver Transplant
NBIC
Nephrology
Neurology
Neurosurgery
Newborn Intensive Care NICU
Occupational Therapy and Physical Therapy
Oncology
Orthopedic
Otolaryngology Head and Neck Surgery
Palliative Care
Pediatric Surgery
Peds ICU
Physical Disabilities
Plastic Surgery
Pulmonary
Radiology and Medical Imaging
Rehabilitation
Rheumatology
Sleep Disorder
Small Bowel Liver Pancreas Transplant
Speech Pathology
Surgical Weight Loss
Thoracic Surgery
Urology
Vascular
Other
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Diagnosis
Does the patient have Medicaid?
Yes
No
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If Medicaid, which state? (Choose N/A if they do not have Medicaid.)
Please select a response
Kentucky
Ohio
West Virginia
N/A
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What is the patient's Medicaid Id / Private Insurance Policy Number? (Type N/A if you do not have Medicaid or Private Health Insurance.)
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Does the patient have Private Insurance?
Please select a response
Yes
No
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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.
Please select a response
Yes
No
NA
Additional Guests / Family Members
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Add Another Guest
Emergency / Additional Contact name
Emergency / Additional Phone
Does anyone in the family have a certified service animal?
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:
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Name of person completing this form
Patient Name ( First and Last )
Phone
Email
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