Thank you for your interest in FSS! Please tell us about you and your family. This will help us better support you at the House and when you go home.

Are you a current or past RMH family, or a family with a child with an illness?

YesNo

Are you a current or past RMH staff, volunteer of family member of an RMH staff member?

YesNo

RMH House

Are you currently staying in the House?

YesNo

Which House?

What is your room number ?

Will you be able to donate the $25 per night ($175 per week) RMH fee?

YesNo

How much could you afford to donate for your stay per night (please do not put a $ in your response)?

RMH House

Please check off what your role is with RMH

I'm an RMH Staff MemberI'm an RMH Staff Member's RelativeI'm an RMH VolunteerOther

Please enter your role with RMH

Which house do you currently work at?

Which house does the RMH staff work at?

Which house do you currently volunteer at?

Relationship To RMH Staff Member

Services Requested

What type of services are you seeking

Individual - for myselfIndividual - for my childCoupleFamily

Please Tell Us About You

First Name

Last Name

Are you an expectant parent?

Yes

Relationship To The Child Receiving/Expected to Receive Treatment

Other Relationship

Your Gender

Your Date of Birth

Click To Pick A Date

Preferred Contact Phone Number

Home Phone

Mobile Phone Number

Work Phone Number

What is your street address?

City

State

Zip

Country

What is your current relationship/marital status?

What is your ethnicity?

Other Ethnicity

Religion

Other Religion

What is your primary language?

Other Primary Language

Do You Speak a Second Language?

Yes

What is your secondary language?

Other Secondary Language

Please Tell Us About You

First Name

Last Name

Your Date of Birth

Click To Pick A Date

Your Gender

What is your relationship to the Patient?

Other Relationship

Preferred Contact Phone Number

Home Phone

Mobile Phone Number

Work Phone Number

What is your street address?

City

State

Zip

Country

What is your current relationship/marital status?

What is your ethnicity?

Other Ethnicity

Religion

Other Religion

What is your primary language?

Other Primary Language

Do You Speak a Second Language?

Yes

What is your secondary language?

Other Secondary Language

Nearest Hospital Emergency Room to You

Hospital Phone Number

Please Tell Us About Your Child

First Name

Last Name

Date of Birth (##/##/####)

Click To Pick A Date

Their Gender

What is their relationship to You?

Other Relationship

Preferred Contact Phone Number

Home Phone

Mobile Phone Number

Work Phone Number

Do They Live With You?

YesNo

What is their street address?

City

State

Zip

Country

What is their ethnicity?

Other Ethnicity

Religion

Other Religion

What is their primary language?

Other Primary Language

Do They Speak a Second Language?

YesNo

What is their secondary language?

Other Secondary Language

Nearest Hospital Emergency Room to You

Hospital Phone Number

Is there another parent/guardian involved with this child?

Yes

Please Tell Us About the Other Parent/Guardian

First Name

Last Name

Are they currently staying at RMH with you?

YesNo

Are they an expectant parent?

Yes

Relationship To The Child Receiving/Expected to Receive Treatment

Other Relationship

Date of Birth

Click To Pick A Date

Gender

Preferred Contact Phone Number

Home Phone

Cell Phone

Work Phone

Do they live with you?

Yes

What is their street address?

City?

State

Zip?

Country

What is their current relationship/marital status?

What is their ethnicity?

Other Ethnicity

Religion

Other Religion

What is their primary language?

Other Primary Language

Do they speak a secondary language?

Yes

What is their secondary language?

Other Secondary Language

Please Tell Us About Your Partner

First Name

Last Name

Date of Birth

Click To Pick A Date

Gender

What is their relationship to You?

Other Relationship

What is their relationship to the Patient?

Other Relationship

Preferred Contact Phone Number

Home Phone

Cell Phone

Work Phone

Do they live with you?

YesNo

What is their street address?

City?

State

Zip?

Country

What is their current relationship/marital status?

What is their ethnicity?

Other Ethnicity

Religion

Other Religion

What is their primary language?

Other Primary Language

Do They Speak a Second Language?

YesNo

What is their secondary language?

Other Secondary Language

Is there another parent/guardian involved with this child?

Yes

Please Tell Us About the Other Parent/Guardian

First Name

Last Name

Are they currently staying at RMH with you?

YesNo

Are they an expectant parent?

Yes

Relationship To The Child Receiving/Expected to Receive Treatment

Other Relationship

Date of Birth

Click To Pick A Date

Gender

Preferred Contact Phone Number

Home Phone

Cell Phone

Work Phone

Do they live with you?

Yes

What is their street address?

City?

State

Zip?

Country

What is their current relationship/marital status?

What is their ethnicity?

Other Ethnicity

Religion

Other Religion

What is their primary language?

Other Primary Language

Do they speak a secondary language?

Yes

What is their secondary language?

Other Secondary Language

If there is no parents please continue

Do you have children?

YesNo

Do you have other children?

YesNo

Child's Information

First Name

Last Name

What is their relationship to You?

Date of Birth

Click To Pick A Date

What is their relationship to the Patient?

Other Relationship

Gender

If I Need to Contact Someone

In the event of an emergency please provide us with a name and contact information for someone we can contact.

First Name

Last Name

What is their relationship to You?

Other Relationship

What is their relationship to the Patient?

Other Relationship

Phone Number

Is there anyone else staying at RMH with you (not previously listed)?

Yes

Are there other individuals important to your child (siblings, grandparents, etc)?

Yes

Information

First Name

Last Name

Relationship to the Child Receiving/Expected to Receive Treatment

Other Relationship

Gender

Date of Birth

Click To Pick A Date

First Name

Last Name

Relationship to the Child Receiving/Expected to Receive Treatment

Other Relationship

Gender

Child's First Name

Child's Last Name

Child's Date of Birth/Expected Delivery Date

Child's Gender

Is the child currently inpatient at the hospital?

Yes

What hospital is the child currently receiving treatment?

Other Hospital

Hospital Department:

Other Hospital Department

What is your child's diagnosis?

Date of Diagnosis

Click To Pick A Date

Does your child live with you?

What is the child's street address?

City

State

Zip Code

Country

Do you have other children receiving treatment?

Yes

Please Tell Us About Your Child Receiving Treatment

Has your child been born?

Yes

Child's First Name

Child's Last Name

Child's Date of Birth/Expected Delivery Date

Click To Pick A Date

Child's Gender

Is the child currently inpatient at the hospital?

Yes

What hospital is the child currently receiving treatment?

Other Hospital

Hospital Department:

Other Hospital Department

What your child's diagnosis?

Date of Diagnosis

Click To Pick A Date

Does your child live with you?

What is the child's street address?

City

State

Zip Code

Country

Do you have other children receiving treatment?

Yes

Child's First Name

Child's Last Name

Child's Date of Birth/Expected Delivery Date

Click To Pick A Date

Child's Gender

Is the child currently inpatient at the hospital?

Yes

What hospital is the child currently receiving treatment?

Other Hospital

Hospital Department:

Other Hospital Department

What your child's diagnosis?

Date of Diagnosis

Click To Pick A Date

Does your child live with you?

What is the child's street address?

City

State

Zip Code

Country

Child's First Name

Child's Last Name

Child's Date of Birth/Expected Delivery Date

Click To Pick A Date

Child's Gender

Is the child currently inpatient at the hospital?

Yes

What hospital is the child currently receiving treatment?

Other Hospital

Hospital Department:

Other Hospital Department

What your child's diagnosis?

Date of Diagnosis

Click To Pick A Date

Does your child live with you?

What is the child's street address?

City

State

Zip Code

Country

First Name

Last Name

Relationship to the Patient?