Go to the Ronald McDonald House Charities of Central Indiana website.
Online Registration
We are so glad you're here! Please complete the following questions as accurately as possible.
*
Patient Name ( First and Last )
*
Patient Date of Birth (MM/DD/YYYY)
*
Guardian/Caregiver Name (First and Last)
*
Primary Phone Number
I agree to receive texts at this number.
*
Do you want to cancel your room request?
Please select a response
No
Yes
*
Reason for canceling room request:
Please select a response
Appointment Canceled or Rescheduled
No Longer Need a Room
Other (Type Answer Below)
Other reason(s) for canceling request:
Modify Check-In and/or Check-Out Dates
If you want to modify the dates of your waitlisted room request, please enter in the comment box your new check-in and check-out dates.
What is your current employment status?
Please select a response
Employed (full-time)
Employed (part-time)
Retired
Student
Unemployed
Self-employed
Help Request Sent
Ok
Make sure the information below is complete and correct and click submit. Someone from the Ronald McDonald House will contact you.
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
Submit
