Please complete the background check authorization form below if you are requesting a stay at Ronald McDonald House Charities of Southern West Virginia. Only parents, guardians, and/or family members with visitation privileges at the hospital are eligible to stay.
Once a background check for each family member (18 and over) and a referral are completed, a Ronald McDonald House staff member will reach out with more information about your stay.
If you have any questions about being referred for a stay at our House, please call (304) 346-0279.
Ronald McDonald House Charities of Southern West Virginia (“RMHC”) conducts a criminal history background check on all individuals (18 years old or older) applying for temporary residence at RMHC. In selecting family members for temporary residence, RMHC screens family behavior and an individual’s suitability for temporary residence among other families. A criminal conviction record that reveals behavior that may adversely affect another individual’s (e.g., other temporary residents, guests, staff, volunteers) health, safety, welfare, and ability to peacefully enjoy the RMHC facility shall result in your application for the temporary residence being denied. For example, and without limitation, convictions of violent crimes, domestic violence, child abuse, sex offenses, illegal drug activity, burglary, and/or identity theft will result in the rejection of your application.
This form includes a Criminal History Background Report Authorization form for you to review and sign. Each family member or overnight visitor (18 years old or older) who intends to apply for temporary residence must separately fill out this form and the Criminal History Background Report Authorization form. Once we receive the completed form, RMHC will have an independent third party conduct a criminal history background check.
RMHC, in its sole discretion, will determine whether your criminal record may threaten an individual’s health, safety, welfare, and ability to peacefully enjoy the RMHC facility and, therefore, result in your application for the temporary residence being denied. You are required to promptly notify RMHC’s staff if your answer to the above-referenced questions needs to be updated. RMHC will in addition make an overall decision on whether the rest of your family will be eligible to stay based on their individual checks.
I certify that all the provided information is accurate, complete, and can be verified. I agree and understand that any falsification, misrepresentation, or omission may disqualify me from seeking temporary residence at RMHC; or if temporary residence already has been granted, then it will subject me to immediate expulsion from RMHC whenever the falsification, misrepresentation, or omission is discovered. I also understand that while RMHC will obtain criminal history background information on potential temporary residents, it cannot and does not guarantee the personal safety of any temporary resident, guest, visitor, or staff member.
RMHC, in its sole discretion, will determine whether your criminal record may threaten an individual’s health, safety, welfare, and ability to peacefully enjoy the RMHC facility and, therefore, result in your application for the temporary residence being denied. You are required to promptly notify RMHC’s staff if your answer to the referenced questions needs to be updated. RMHC will in addition make an overall decision on whether the rest of your family will be eligible to stay based on their individual checks.
To assist you in truthfully and completely answering this form, please be advised your application will be in jeopardy if you have been convicted of any of the following criminal offenses (whether or not the offense may have been labeled in another way in your state or country of residence). This list is not all-inclusive.
I certify that all the provided information is accurate, complete, and can be verified. I agree and understand that any falsification, misrepresentation, or omission may disqualify me from seeking temporary residence at RMHC; or if temporary residence already has been granted, then it will subject me to immediate expulsion from RMHC whenever the falsification, misrepresentation, or omission is discovered. I also understand that while RMHC will obtain criminal history background information on potential temporary residents, it cannot and does not guarantee the personal safety of any temporary resident, guest, visitor, or staff member.
A referral from a hospital social worker or doctor’s office (for outpatient appointments and procedures) must be completed and faxed to Ronald McDonald House Charities of Southern West Virginia. Once a referral and all background check forms for all family members have been received, a Ronald McDonald House staff member will contact you about room availability .
Parents don’t know when their children will need medical help. But they should know they can always access the care they need. And with your help, we can support them all throughout their journey.
