Online Registration

WELCOME

By submitting a room request, you acknowledge that you have reviewed and understand our eligibility requirements.

Have you stayed at Ronald McDonald House Charities of Greater Cincinnati in the past?

If yes, have you stayed in the past 2 years?

Will any guests staying at the House have an open Child Protective Services case?

PATIENT INFORMATION

Please check this box if you are a fetal care patient, if so, please input baby's information below and your information will go under "Guardian Contact Information."

* Patient Name ( First and Last )

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

* Patient Gender

* Patient Ethnicity

* Diagnosis

* Assigned Social Worker / Hospital Staff

Physician/Doctor

* Patient is being treated at:

* Department

Speciality

* Will the patient be inpatient or outpatient?

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

* Date of first appointment at hospital

Appointment Time

* Check In Date

* Check Out Date

* Primary Language

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

PO boxes are not permitted

GUARDIAN CONTACT INFORMATION

* First Guardian Name

* Relationship to patient

First Guardian Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Email

* Primary Phone Number

I agree to receive texts at this number.

You will receive a text from SlickText, please respond YES to opt in. Standard messages and data rates apply.

Second Guardian Name

Relationship to patient

Second Guardian Gender

Date of Birth (MM/DD/YYYY)

* Ethnicity

Primary Phone Number

I agree to receive texts at this number.

You will receive a text from SlickText, please respond YES to opt in. Standard messages and data rates apply.

ADDITIONAL GUEST(S) INFORMATION

Will there be any additional guests at the House throughout your stay? Please enter their information below (siblings, grandparents, service animals, etc).

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

Add Another Guest

ADDITIONAL INFORMATION

* Emergency Contact Name (not expected to stay with you)

* Emergency Contact Phone

Will you have a vehicle in Cincinnati?

Parking is limited at the House. Your family may need to park at the hospital during your stay.

* Car Make/Model/Description

* Car License State

* License Plate#

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

Does the patient have Medicaid?

Does the patient have Private Insurance?

* What is the patient's Medicaid Id / Private Insurance Policy Number? (Type N/A if you do not have Medicaid or Private Health Insurance.)

* If Medicaid, which state? (Choose N/A if you do not have Medicaid.)

If Private Insurance, who is your insurance provider? (type N/A if you do not have private insurance)

ACCOMMODATION REQUEST(S)

If there are no other rooms available, would you be able to accept a room with only 1 bed?

Do any guest(s) in your family use a wheelchair or other mobility medical equipment?

Yes No

Does your family need access to any of the following during your stay? (Pack n' play, rollaway bed, breast pump, bed rail, baby bathtub)