* ¿El paciente que recibe atención tiene 21 años o menos?
* ¿Vive en el condado de Jefferson, KY, o en los condados de Floyd/Clark de Indiana?
* ¿Se ha hospedado en RMHC Kentuckiana en el pasado?
* En caso afirmativo, ¿ha estado en los últimos 30 días?
* Confirme que comprende que la disponibilidad de habitaciones cambia todos los días. Completar el registro en línea no garantiza una estadía.
* “I understand” “Ronald McDonald House Charities of Kentuckiana will conduct a formal public sex offender check for all individuals 18 years of age or older. This measure is to ensure the safety and security of all families, which is of utmost importance to us. Persons who appear on the national sex offender registry will be denied lodging.”
Please confirm that you understand if your stay exceeds 30 days you may be asked to switch rooms or a deep clean of your current room may be required.
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Guest acknowledges that Guest is receiving temporary lodging at a private, non-profit institution, that such residence is incidental to the provision of medical or similar services to a child of Guest, that such temporary lodging is similar to a hotel room, and that Guest does not have a right to exclusive possession of the room(s) Guest is assigned by RMHCK.  Guest further acknowledges that this is not a rental agreement as defined by KRS 385.545(11), nor is Guest considered a tenant for purposes of the Kentucky Landlord Tenant Act or other applicable law.
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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

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Guest Guidelines

Welcome to our Ronald McDonald House! We are here to provide your family a comfortable “home-awayfrom-home” close to the hospital while your child is undergoing medical treatment. It is our expectation that a significant amount of your time will be spent at the hospital with your child. Our House is a communal living environment, and we ask each family help keep the common areas tidy by cleaning-up after use. While staying at the Ronald McDonald House Charities of Kentuckiana (RMHCK) families are expected to abide by the House rules listed below and in the information binder located in your room.

Recent Exposure to Contagious Disease – Due to the possibility of passing an illness to a patient being treated at the hospital or a patient residing at RMHCK NO GUEST can reside at the House who has had a recent exposure (within past 1-14 days) to an illness considered contagious (i.e., COVID, monkey pox, measles, flu, strep, scabies, chicken pox, head lice, hepatitis, mumps, tuberculosis, mononucleosis, bacterial meningitis, etc.). Please notify the Guest Services staff at the Front Desk if you experience symptoms that could potentially be a contagious disease.

Room Policy – No more than six people, including babies, to a room. Registered guests are expected to use the room each night. Exceptions may be made from time to time for one night only. However, you must speak with Guest Services staff before leaving the House. When the child is discharged from the hospital or clinic, the family is expected to checkout. Anyone 16 years of age or older is required to wear a RMHCK wristband for the duration of their stay. IMPORTANT: Guests are NOT allowed to visit inside another guest’s room. Common areas (dining room, playroom, kitchens, etc.) are provided for this purpose.

Respecting Others - Guest Services staff are available from 9am-9pm to assist families with making your stay as comfortable as possible. Security Officers supervise and monitor the House from 10pm-8am. Security and Guest Services Staff are responsible for enforcing House Rules; disrespect of any kind towards others (staff, Guests, and volunteers) will not be tolerated. Guest will not be able to access the House with their room key between 10pm-6am, therefore you will need to be buzzed in by Security. Guests will need to provide your Room number and Last name each time you need to be buzzed in.

Smoking – Smoking, vaping, and the use of tobacco products is prohibited inside the House. Please do not smoke within 50 feet of any entrance/exit of the House or near the playground. Children – Parents must supervise children under the age of 16 at all times. Children may not be left under the supervision of other house guests.

No Hit Zone – This facility is a “No Hit Zone.” A “No Hit Zone” is an environment in which: No adult shall hit another adult. No adult shall hit a child. No child shall hit an adult. No child shall hit another child.

Check Out – Check out hours are between 9am and 3pm. All families will be required to follow proper Checkout procedures. When you are ready to check out come to the Front Desk to get the Check-out List. Make sure to give yourself at least 30 minutes to complete the check-out process. Guests who leave without checking out properly will not be allowed to return to RMHCK.

Quiet Hours – Quiet hours are from 10pm – 9am daily. Some lights will be turned off at 10pm and will remain off until Quiet hours are over. You may continue to use the common areas as long as you are quiet. Guest Guidelines Rev. 1/29/21

Visitors – Visitors are welcome from 9am to 9pm daily. Visitors are only allowed on the main level. Please signin visitors at the Front Desk at each visit. You are responsible for the behavior and conduct of individuals visiting you. All rules apply to visitors.

Parking Lots – The parking lot located on 1st street is designated for all guests staying at RMHCK. The rear parking lot located on Chestnut Street is designated for guests who require wheelchair access, RMHCK staff, and volunteers.

Dress Code- Shoes or slippers are required at all times. All residents need to have appropriate clothing (shirt, pants, robes) on the outside of their room.

Zero Tolerance leading to immediate eviction:
• Smoking anywhere inside the House
• Possessions of alcohol, illegal drugs, weapons (including concealed) on House property
• Room abandonment
• Violation of a Final Warning
• To be under the disabling influence of alcohol and/or drugs

AUTHORIZATION TO RELEASE PROTECTED HEALTH CARE INFORMATION

     Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), representatives of the Ronald McDonald House Charities of Kentuckiana (“RMHCK”) requests the following Private Health Information as it pertains to my child and/or children: scheduled appointments, discharge summaries, and order and progress notes concerning medical treatment that he or she has received from you, at your institution. This information is to verify there is a clinical need for my family to continue their stay at RMHCK and to help assure that RMHCK is making good decisions regarding utilization of its facilities and resources. This information is also used for the purpose of maintaining a safe environment for guests staying at RMHCK. Information obtained by RMHCK will not be released to other families staying at its facilities, nor will it be sold or exchanged with other third parties. Medical providers may not condition treatment or payment on whether the patient executes this authorization.

Medical Onsite Home Healthcare Policy

Please be advised that all Guests staying at the RMH will be asked to sign acknowledgement of the Medical Onsite Home Healthcare Policy if they require any of the following:

• Medical Procedures
• Medical Devices and Equipment
• Delivery of Medication and/or Medical Supplies
• Clean-up and Disposal of Medical Waste
• Sharps


Photo Release Ronald McDonald House Charities® (RMHC®) Grant, Assignment, Release and Waiver

I hereby grant to Ronald McDonald House Charities, its affiliates, subsidiaries, franchises, advertising and promotional agencies, and their agents and representatives, any of its Chapter organizations (defined as an entity having the right to Ronald McDonald House Charities, Ronald McDonald House, Ronald McDonald Family Room, and/or Ronald McDonald Care Mobile, or other trademarks for charitable purposes) (collectively, “RMHC”) and McDonald’s Corporation, its affiliates, subsidiaries, franchises, advertising and promotional agencies, and their agents and representatives (collectively, “McDonald’s”), the irrevocable, unrestricted worldwide right to use, publish, display, broadcast, edit, modify and distribute materials bearing my name, voice, image, likeness and/or any other identifiable representation of myself (collectively, “My Likeness”.) These materials may appear in any form, style, color or medium whatsoever now known or later developed (including, without limitation, photographs, videotapes, films, sound recordings, software, drawings, prints, broadcast, internet and electronic media.) McDonald’s use of My Likeness will be limited to use involving raising awareness of or for support of RMHC.

I agree that all materials containing my likeness (including, without limitation, all negatives, plates and masters of any photographs, files, prints or tapes) shall be and remain the sole and exclusive property of RMHC and/or McDonald’s, and I hereby assign any right I may have acquired in or to such material to RMHC and/or McDonald’s. I hereby release and forever discharge RMHC and/or McDonald’s from any and all claims, liabilities and damages relating to the use of My Likeness. I hereby waive any right I may have to inspect or approve the finished materials or any part or element thereof that incorporates My Likeness.

I have agreed to the above in consideration of the opportunity given to me by RMHC and/or McDonald’s to appear in these materials. I acknowledge that I have fully read and understand this document and that I have had any questions regarding its effect, or the meaning of its terms answered to my satisfaction. I certify that I am at least 18 years of age unless this document is also signed by my parent or legal guardian.
* I represent that I am a parent or legal guardian of the patient. I understand the above and consent to the use of his/her likeness as set forth above.
* Electronic Signature:


**For your safety and security, do not let anyone into the house that is not registered as a guest. Be attentive while entering and exiting the building to ensure no one is coming in behind you.
I understand that injuries or damages could occur by natural causes or activities of other persons, staff of RMHK or other third parties, either as a result of negligence or because of other reasons. I appreciate that I may have to exercise care for my own person and for others around me.
**For continued eligibility, the patient must have a continuum of weekly medical care with a minimum of 3 visits per week with separate dates of service.
**A significant amount of daily participation and visitation with the patient is expected during your stay (4-6 hours per day). Not meeting this expectation will jeopordize stays at RMHCK.
**Guest rooms must be used on a daily basis. Guests with repeated non-use of room within a 24-hour period may forfeit their continued stay with RMHCK.
**Visitors restricted to main level (Private intake room, Dining Area, Front Lobby, Play room)
**Notify Front Desk if you experience symptoms that could potentially be a contagious disease
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.”
By signing below, you acknowledge that you have read this document and grant the House permission to enforce it if needed at any time during your stay.


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:


* Guardian 1 Electronic Signature:
Guardian 2 Electronic Signature: