Ronald McDonald House - Oak Street Family Application

 

Reminder-

  • All families who wish to stay at Ronald McDonald House Oak Street are required to complete the Guest Application and Background Check Disclosure.Once this application has been processed and a social worker referral has been received, you will receive an email invitation from MBI WORLDWIDE to complete the online criminal background check.
  • All guests who are 18 and over are required to pass a criminal background check prior to checking into the House.
  • After the online background check results have been processed, a staff member will contact you to discuss results and room availability.. 
 

PATIENT INFORMATION

  Please provide information about patient

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Name:

 

 

   

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City/State/ZIP:

 

    

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Date of Birth:

 

If you respond and have not already registered, you will receive periodic updates and communications from Ronald McDonald House Charities Upper Midwest.

 


   


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Treatment & Facility Details

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Question - Required - Patient Status


 

When do you need to come stay with us, and for how long?

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Question - Required - Anticipated length of stay




 

Primary Guest (Who is going to be the main person that we can coodinate with ?)

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Other Guests 18 and over

Who else will need to stay with you?

Due to high demand for services and occupancy restrictions, accomodations are limited to those family members that are: 1) involved in the daily care of the patient, 2) primary support person for the parent/guardian or 3) in the direct supervision of the siblings. Most rooms sleep 2-6 people comfortably. All rooms do have occupancy restrictions and RMHC reserves the right to limit the number of people in each room

All guests age 18 and older are required to pass a Criminal Background Check prior to checking into the House. Please note that ONLY those listed on this application will receive the background check instructions. Those that are not listed will not be able to complete the process.

RMHC-UM reserves the right to refuse admittance to any potential resident or guest with a criminal conviction. RMHC-UM does not admit anyone with a criminal conviction that may threaten the health, safety, welfare and ability of other individuals to peacefully enjoy the House this includes but is not limited to violent crimes, domestic violence, child abuse, sex offenses, illegal drug activity, stalking, burglary, robbery, theft or fraud.

RMHC-UM also will not admit any individual who provides false, incomplete, or misleading responses during the formal criminal history background check process.

Ronald McDonald House will pay for up to 5 background checks per family. If additional background checks are requested, please call the House at 612-805-3467 or you can make payment during the background check process. Background checks are $9.00 per person.

List all guests who will be staying at the house

PLEASE NOTE- You do not need to enter the primary contact or the patient in this section.

 

List guests who will be staying at the House who are 18 and over

   


   


   


   


   


   


   


   


   


   


   


   


   


   


   


   


 

Guests 18 and Under 

Children ages 18 and under are welcome to accompany their families and stay at the House. Guests under the age 18 will need to be in good health and are required to be accompanied by a responsible adult at all times when in the House. 

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Question - Required - Primary Language



   


 

Billing/Medical Insurance

Ronald McDonald House Charities, Upper Midwest provides a temporary home-away-from­home for families with seriously-ill children undergoing medical treatment. We are a non­profit 501(c)(3) public charity. It costs Ronald McDonald House Charities, Upper Midwest $165.00 per night to provide housing to each family at our Ronald McDonald House – Oak Street location.

We currently seek to recover $60 per night in situations where families have medical assistance or private insurance to cover housing costs. Preauthorization is required from your medical assistance provider in order for us to bill.

If you don’t have coverage for housing costs, we encourage a voluntary contribution of $25.00 per night to be made if you are able. However, any contribution is appreciated. No eligible family is ever turned away or asked to the leave because they are unable to make a financial contribution towards their stay. 

Please call your county/state financial worker or member services to access your lodging/travel benefits and receive a preauthorization prior to checking into the Ronald McDonald House. Bring this preauthorization information to the check in. 

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Question - Required - Please check one or multiple coverage if applicable:
Please make between 1 and 2 selections from the choices below.

   


   


   


   


   


 

Criminal History Background Check Authorization

Thank you for your inquiry to stay Ronald McDonald House Charities-Upper Midwest Oak Street. We hope to assist your family during this challenging time.

Ronald McDonald House Charities-Upper Midwest (RMHC-UM), in order to undertake reasonable efforts to protect the safety of the guest families residing with us, now requires that each individual applicant (age 18 or older) who applies to stay at Ronald McDonald House Oak Street to undergo a formal inquiry into their background (“background check”) to assess whether the guest applicant should not be permitted access to our facilities. This background check will include a private, multi‒jurisdictional database of criminal records, as well as, a search of the National Sex Offender Public Registry for each individual age 18 or older.

All guest applicants are required to go through this process. You have the right to decline to have this background check performed. However, if you do decline the background check, we will have no choice but to deny your request for access to our facilities out of the need to take all reasonable efforts to protect the safety of our families. Please understand that RMHC-UM solely will obtain a background check to assist it in determining whether to grant you access to our facilities. RMHC-UM is not obtaining a “consumer report” for any other purpose. RMHC-UM will not be conducting a credit check. By accepting this authorization, you authorize us to obtain the background report described in it from a consumer reporting agency.

This background check will be conducted by a third party. Results of the background check are sent directly to RMHC-UM. The information obtained during the background check process will only be used by RMHC-UM to determine whether to grant access to our facilities and will only be divulged on a “need to know” basis to those individuals or entities that it deems necessary to review that information. The information will not be disclosed for any other reason. In order to protect the health, safety and welfare of our guest families, an individual will “fail” the background check if they have a history of criminal activity that violates the  RMHC-UM policy:

RMHC-UM reserves the right to refuse admittance to any potential resident or guest with a criminal conviction. RMHC-UM does not admit anyone with a criminal conviction that may threaten the health, safety, welfare and ability of other individuals to peacefully enjoy the House (e.g. violent crimes, domestic violence, child abuse, sex offenses, illegal drug activity, burglary, robbery, theft or fraud.

RMHC-UM also will not admit any individual who provides false, incomplete, or misleading responses during the formal criminal history background check.

If you have failed the background check, you will need to find other accommodations. Other individual members of your family/group, who pass the background check may be permitted access to our facilities with a passing background check. The background check will be performed by MBI Worldwide® The toll‒free telephone number that you can use to contact MBI Worldwide® is 1‒866‒275-4624. MBI World wide’s address is 200 Central Ave Suite 820 St. Petersburg, FL 33701 United States. You have important rights under the Fair Credit and Reporting Act that you can exercise by contacting MBI Worldwide. If MBI Worldwide reports negative information to us causing you to fail our background check, you can obtain a copy of your report from MBI Worldwide free of charge. You can dispute any inaccurate, incomplete, or out‒of‒date information in MBI World wide’s Report by contacting MBI Worldwide®. If you do, MBI Worldwide will re‒investigate the information that you dispute, remove or correct any inaccurate or incomplete or out‒of‒date information, and send us a replacement report. MBI Worldwide will also take steps to prevent any inaccurate or incomplete or out‒of‒date information from appearing in any future reports they prepare about you.

In addition to this policy, RMHC-UM reserves the right, in its sole discretion, to expel a guest for any inappropriate, irresponsible or criminal behavior that takes place while temporarily residing at one of our Houses. While RMHC -UM has implemented this background check policy in order to take reasonable efforts to protect the safety of our guest families, RMHC-UM cannot and does not warrant or guarantee the personal safety of any temporary resident, guest, visitor or staff member.

Please confirm that you have read and understood the above

 


About MBI Worldwide and a Summary of Your Rights

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When your application form has been processed you will receive an email invitation from MBI WORLDWIDE® to complete the background check.

Please note that only those listed on the initial and received the background check instructions can continue to the background check process.

To learn more about your consumer rights, please refer to a summary of your rights under the Fair Credit Reporting Act (.pdf).

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Health Screening/Infection Control

At time of intake, your family will complete a health screening questionnaire to screen for specific illnesses. Some specific illnesses of epidemiological significance require a signed medical clearance document, confirming that the family members are not an infectious risk to guests, staff, and volunteers. 

Please read the Ronald McDonald House Guidelines and Expectations and sign off below. 

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