Guest Registration

Today's Date

Please contact me regarding:

Overnight Guest RoomDay Guest

Guest Contact Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Please list all siblings/guests staying in room

Primary Home Address

City

State

Zip Code

County of Residence

Primary Phone Number

Primary Email Address

Secondary Phone Number

Secondary Email Address

If someone would call and ask for you, can we let them know you're a registered guest?

Have you been a guest with Ronald McDonald House Charities of Northeast Indiana in the last six months?

Patient Information

Patient Full Name

Patient Room Number

Child Staying On

Media Release:

I hereby grant Ronald McDonald House Charities of Northeast Indiana (RMHC NEIN) the irrevocable right to use, publish, display, broadcast, edit, modify and distribute materials bearing my name, voice, image, or likeness (collectively, “My Likeness”.) Materials may appear in any form, style, color or medium. My Likeness will be limited to use involving raising awareness of or support of RMHC/RMHC NEIN. I hereby release and forever discharge RMHC NEIN, 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 that incorporates My Likeness.

I agree to the terms of the media release:

YesNo

Please enter your name below as acknowledgement of and agreement to the following: I/we understand it is a privilege to be a guest for the purpose of attending to the needs of my child. I/we also understand privileges will extend as long as the child remains hospitalized/receiving outpatient services and the parents are participating in the child's care. I/we also understand that if I/we, or any of my visitors abuse privileges, policies, or procedures, we will be asked to find other accommodations.

I/we authorize Ronald McDonald House Charities of NEIN to communicate with any medical institution, medical and mental health professionals, or social service agency regarding information which Ronald McDonald House Charities of NEIN deems necessary.

I understand and agree for myself, my family and my visitors to release and discharge Ronald McDonald House Charities of NEIN, its Board of Director(s), officer(s), employee(s), volunteer(s), affiliate(s),associate(s) and any other person related will not be responsible or any loss of or damage to me, my family member’s or visitor’s property that occurs in the Ronald McDonald House thereto from all liability, claims, demands, injuries, damages, action or causes of action which may occur with respect to any loss, damage, injury, illness, or other damages which arise out of or are connected with the occupancy, and/or use of the Ronald McDonald House Charities of NEIN.

Signature

Contact Information