General Stay Request

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General Stay Request

1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

Request completed by

Staff

Social Worker

Social Worker Alternate Phone

Social Worker Alternate Email

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

Ethnicity

Diagnosis

Facility Treated At

* Inpatient - Hospitalized

COVID-19 Information

Vaccination Status

Vaccine Name

# Vaccinations

Country

First Vaccination Date

Second Vaccination Date

Booster Vaccination Date

Exemption Note

Vaccination Note

Does patient have private insurance?

Has patient been exposed to any contagious disease?

Yes

No

Name of Treating Doctor

Other Patient Information

Add Another Patient

3. Guest Information

* First Name

Middle Name

* Last Name

Gender

Date of Birth

* Relationship to Patient

Contact Information

Email

Type of Email

Home Phone

* Mobile Phone

By providing your mobile number, please accept to get text messages from our organization. Message and data rates may apply. Visit our website for terms and privacy information. To stop texting, do not accept.

I accept to receive text messages on this number

Type of Address

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

Check this box to enter your vehicle information

COVID-19 Information

Vaccination Status

Vaccine Name

# Vaccinations

Country

First Vaccination Date

Second Vaccination Date

Booster Vaccination Date

Exemption Note

Vaccination Note

Have you stayed with us before?

Yes

No

Other Guest Information

Add Another Guest

4. Additional Information

Do you give RMHC permission to use any photos, artwork, or videos taken/created including the first name, age, and diagnosis of our child.

Are there any special needs for your family? (wheelchair, etc.)

Language Interpreter

Needed Language

Notes regarding this request:

Acceptance

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

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My RMHC Chapter
123 Nonprofit Lane
Give City, State 12345
info@yournpo.org

Demo Credit Card
Visa 4007000000027 CVV 111
Exp any date after today

Demo eCheck
John Doe
Routing 121141754
Acct: 7687245428
Type: Checking

Max USD100

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