Staff Registration

Your Name

Phone

Patient Information

* Patient Name ( First and Last )

* Patient Date of Birth (MM/DD/YYYY)

Patient Gender

* Patient Ethnicity

Patient is being treated at:

Will the patient be inpatient or outpatient?

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

Department

Diagnosis

Guardian/Caregiver Information

* 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.

* Email

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

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.

Additional Guests

Below please enter the information for any additional guests that will be staying overnight at the House such as siblings, grandparents, aunts, uncles, cousins, etc. Visitors are welcomed during our visiting hours, but do not need to be added to this request unless they are staying overnight. All guests and guardians over the age of 18 are asked to complete a background check prior to staying.

Will there be any additional guests outside of the guardian(s) listed above?

Yes No

Additional Guests / Family Members: I agree to receive texts at this number.

Add Another Guest

Additional Information

What language does the family prefer to receive verbal or written communication in?

Do any of the overnight guests use a wheelchair or other mobility device that we should be aware of?

Yes No

Will the family have a vehicle on the premises?

* What is the family's requested check in date? (Please note that we are unable to guarantee room availability on the requeste date.)

* What is the family's estimated check out date?

Family Support and Resources

If possible, please have the applying family help fill out this section.

The following questions will help Ronald McDonald House Central Indiana identify gaps in resources, services, and support. All information will remain confidential.

Does the patient have Medicaid? (Note this information does not impact your ability to stay and it will not cost you)

Does the patient have Private Insurance?

What is the patient's Medicaid ID/Private INS. # (Type N/A if you do not have Medicaid or Insurance)

Medicaid State (Choose N/A if you do not have Medicaid)

If Private Insurance, who is the patients provider? (Type N/A if you don't have)

What is your current employment status?

Which of these describes your total household income? (Note: This information is only used in securing funding for the House.)

Do you currently receive any governmental assistance with any of the following?

Food Stamps (SNAP)

Yes No

Housing Assistance (Section 8, Public Housing)

Yes No

Unemployment Benefits

Yes No

Social Security

Yes No

Disability Benefits

Yes No

Other (please specify)

How many people live in your household?

Have you experienced a recent financial hardship (such as job loss, medical expenses, or other unexpected expenses)?

Yes No

Do you rent or own your home?

Are you currently at risk of eviction or losing your housing?

Yes No

Which of the following resources do you or your family have an immediate need for?

Food and Groceries

Yes No

Utilities (electricity, water, gas)

Yes No

Transportation (fuel, public transportation, Lyft)

Yes No

Health Care/Medical Needs

Yes No

Personal Care/Hygiene Products

Yes No

Educational Support (e.g., school supplies)

Yes No

Other (please specify)

Do you feel you have access to adequate emotional support (e.g., counseling, community resources, or mental health services)?

What type of emotional support do you feel would most benefit you and your family?

Counseling or Therapy

Yes No

Peer Support Groups

Yes No

Stress Management Tools

Yes No

Mental Health Hotlines

Yes No

Other (please specify)