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Guest Stay Online Request Form

1. Stay Request To Be Completed by Social Workers


2. Patient Information

Does patient have private insurance?


3. Guest Information

Contact Information
Need a parking space while staying with us?


4. Additional Information

Are there any special needs for your family? (wheelchair, etc.)
Do you give RMHC permission to use any photos, artwork, or videos taken/created including the first name, age, and diagnosis of our child.
Language Interpreter
Needed Language
Room Type

Notes regarding this request:



Acceptance
Your request will be processed. Do you want to continue?

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