Springfield Ronald McDonald House Overnight Guests

Hospital Case Worker First and Last Name

* Patient Name: * If patient is unborn, put "Baby" as first name and Mom's last name.

* Patient Date of Birth: If patient is unborn, enter the due date as the date of birth.

* Patient Gender

Patient Ethnicity

* Diagnosis

* Department

* Briefly explain your child's situation.

Will the patient be inpatient or outpatient?

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

* Patient is being treated at:

Name of originating or home hospital?

Town of originating or home hospital?

Does anyone in the family have a service animal? While family pets and companion animals are not allowed in the Houses, service animals are welcome.

No Yes

Stay Dates:

* Date of first appointment at hospital

* Preferred Check-in Date

* Expected Check Out Date (If NICU, use due date)

Guardian/Caregiver Information:

Parent/Guardian must be at least 18 years old. If one or both parents/guardians are under 18, you'll need to complete our "Assign a Guardian" form upon check-in.

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Ethnicity

* Primary Phone Number

I agree to receive texts at this number.

* Guardian Email (type N/A if no email)

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Ethnicity

Primary Phone Number

I agree to receive texts at this number.

Emergency Contact:
Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the family.

* Emergency Contact Name (first and last):

* Emergency Phone:

Family Information:

* Primary Language

Patient's Address
(If family does not have a permeant address, please call 309-401-2525 to discuss).

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Ronald McDonald House Central Illinois welcomes all families. We celebrate a varity of holidays throughout the year. If you would like to share, what holidays might your family recognize or celebrate while staying with us?

Additional Guests:

Additional Guests / Family Members: Add Another Guest

Vehicle Information:

Family's method of transportation to the hospital or our House (personal car, hospital shuttle, car for hire, etc)?

Will you have a vehicle on premises?

Car Make/Model/Description

Car License State

License Plate#