Other Information
1. Is the family appropriate for community living? (i.e., Sharing common areas like kitchen dining room and may share a bathroom with one other family.) Yes No
2. Are all guests free from exposure to any infectious disease such as: chicken pox, shingles, measles, mumps, meningitis, respiratory infections, tuberculosis, conjunctivitis, scabies, strep throat, the flu or any contagious skin conditions within the last 30 days? Yes No
3. Are all guests free from exposure to bed bugs and head or body lice within the last 30 days? Yes No
4. Are all guests being referred free from any current investigation involving child, spouse, alcohol or drug abuse? Yes No
5. Is this family/guest(s) currently free from any open Department of Child Safety cases? Yes No
Infectious Disease Prevention Regarding the Coronavirus
6. Do you or anyone intending to stay with you during your time here at the Ronald McDonald House have a travel history from China, South Korea, Japan, Iran, or Italy within the past 14 days? Yes No
7. Have you or anyone intending to stay with you during your time here at the Ronald McDonald House knowingly had contact with a traveler who recently visited China South Korea, Japan, Iran, or Italy within the past 14 days? Yes No
8. Have you or anyone intending to stay with you during your time here at the Ronald McDonald House knowingly had contact with someone who tests positive for COVID-19? Yes No
9. Have you or anyone intending to stay with you during your time here at the Ronald McDonald House shown symptoms of a fever, cough, or shortness of breath? Yes No
Is any family member in need of wheelchair accessibility or have any other special needs? Yes No Will the child receiving medical treatment be residing at the House? Yes No
By submitting this form the referring professional accepts responsibility for understanding the Ronald McDonald House Occupancy and Room Request Guidelines and has confirmed that this family meets the requirements for temporary lodging at RMHC Phoenix. All requests will be placed on the Waiting List in the order received. RMHC cannot guarantee a room.
If you have any questions regarding the appropriateness of a family please feel free to contact a staff member at 602-264-2654
