Online Registration

Ronald McDonald House Charities Columbia, SC

Rooms cannot be reserved or held in advance.

* Date the Room is Needed:

* Approximate Check Out Date:

* Number in Guest Family Party:

Please fill out the following with the PATIENTS information:

* Full Name:

* DOB:

* Sex:

* Patient Ethnicity

* Critical Level

Address:

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

* Diagnosis

* Department

* Will the patient be inpatient or outpatient?

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

* Referring Agent:

* Phone Number:

* Email

* Referring Facility:

Guest Family/Accompanying Guests

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Email

* Primary Phone Number

Second Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Primary Phone Number

Additional Guests / Family Members: * * *

Add Another Guest

* Do you or anyone in your guest party currently have an open case and/or are under investigation by law enforcement or any state child protection division for child abuse and/or neglect?

Comments / Additional Needs