Application

* Is the patient receiving care 21 years of age or younger?

* Do you live in Jefferson County KY, or Floyd/Clark Counties of Indiana?

* Have you stayed at RMHC Kentuckiana in the past?

* If yes, Have you stayed in the last 30 days?

* Please confirm you understand that room availability changes daily. Completing online registration does not guarantee a stay.

* Patient Name ( First and Last )

* Patient Date of Birth (MM/DD/YYYY)

* Patient Gender

* Patient Ethnicity

Date of first appointment at hospital

Check In Date

Diagnosis

* Department

* Guardian/Caregiver Name (First and Last)

Ethnicity

* Email

* Primary Phone Number

* Date of Birth (MM/DD/YYYY)

Second Guardian/Caregiver Name (First and Last)

Ethnicity

Date of Birth (MM/DD/YYYY)

Primary Phone Number

Does anyone in the family have any food allergies? If yes please list their name, age, and the allergy.

* Emergency Phone

* Emergency Contact

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

State/Province

Zip

Car Make/Model/Description

Car License State