Online Registration

Your Name

Phone

Have you stayed at Ronald McDonald House Stanford in the past?

Have you stayed at another RMHC location? Where?

* Patient Name

* Patient Date of Birth

Patient Gender

* Pentient ethnicity

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

* Patient is being treated at:

Department

* Diagnosis Description

* Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

Assigned Social Worker / Hospital Staff

Physician/Doctor

* Date of first appointment at hospital

* Check In Date

* Check Out Date

What is your main health insurance?

Does the patient or family have health insurance?

If you marked yes for the question above, please provide us with

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

* Primary Language

* Primary Phone Number

I agree to receive texts at this number.

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Primary Phone Number

I agree to receive texts at this number.

Additional Guests / Family Members: Add Another Guest

Please write-in the total monthly income for your household. (Do not include decimals)

How many people are you financially responsible for that live in your home, including yourself?

Is everyone able to do stairs?

Are there any special needs for your family? (wheelchair, breast pump, fridge, freezer, pack n play, etc.). If yes, please describe below.

Are there any contact isolation precautions for the patient or anyone in your family that will be staying at the House? If yes, please explain.

Can family be contacted via text/email message?

Yes No

Does family have a credit/debit card?

Yes No

If preferred language is not listed, please list here:

Please share additional details that you'd like our Ronald McDonald House team to know about your family or this housing request below: