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¿Se ha alojado en RMHC Kentuckiana en los últimos 30 días?
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¿Vive en el condado de Jefferson, KY, o en los condados de Floyd/Clark de Indiana?
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Will any guest staying at the House have an open Child Protective Services case?
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Will the patient be inpatient, out-patient or both during this stay?
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Patient is being treated at which Medical facility?
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Will you have a vehicle in Louisville? Parking is limited at the House. Your family may need to park at the Hospital during your stay. The Chestnut Street parking lot is only for families that need ADA access.
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Date of appointment (understanding that Doctors appointments are a one day stay unless otherwise noted on referral)
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Appointment time
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Primary Language
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Does the family require ADA accommodations?
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Acepto recibir mensajes de texto en este número.
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RMHCK can text me with important information
Búsqueda postal de EE. UU. / Canadá


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Acepto recibir mensajes de texto en este número.
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Does anyone in the family have any food allergies? If yes please list their name, age, and the allergy.
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Invitados adicionales / miembros de la familia

Agregar otro invitado

Demographic Questions
 
Is anyone staying at RMHC Kentuckiana a veteran?
Total Household Income Level
The following questions will only be used for reporting purposes.
Please list the place of employment for Each Guardian:
Guardian One Employer:
Guardian Two Employer:

Ronald McDonald House Charities of Kentuckiana is NOT responsible for personal injury, medical care or loss of personal property. My signature below acknowledges the preceding and the agreement to abide by all House rules contained in the Guest Guidelines that I received at check in. Also, Ronald McDonald House incorporates by reference in this registration form the document titled, “Authorization to Release Protected Health Care Information.”
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Guardian 1 Electronic Signature:
Guardian 2 Electronic Signature: