Request A Room
- Families must complete a referral form signed by a medical professional involved in their child’s treatment. Click a link below to download the hospital specific form or request a form from your hospital.
- All individuals over 18 years of age requesting services must:
- Complete a criminal history background report authorization form. Click the link below to submit an online application or request a form from your hospital.
- Background Report Authorization (Printable PDF Version)
- Provide a valid, state issued photo ID upon registration & review the Summary of Rights.
- Referrals can be submitted to the House through fax or e-mail
- 937.496.2476 or [email protected]
Once the referral is received, a Guest Services Manager will contact the family regarding their eligibility and the availability of a room. When determining availability, RMHC Dayton considers several factors, including the criticality of the child’s condition and the distance their family must travel to and from the hospital.
For more information, contact Guest Services at 937-224-0047, or email [email protected].
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