Room Request

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

Patient Information

* Patient Name ( First and Last )

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

* Medicaid ID (Patient's with Delaware Medicaid should enter 10-digit Medicaid ID the begins with a series of zeros)

If Medicaid, which state? (Select N/A if the patient does not have Medicaid)

* Patient Gender

* Patient Ethnicity (for grant purposes only)

* Diagnosis

Stay Information

* Reason For Stay

* Department

* Patient is being treated at:

Assigned Social Worker / Hospital Staff

Physician/Doctor

* Will the patient be inpatient or outpatient?

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

* Date of first appointment at hospital

Please provide the patient's appointment/procedure schedule below.

* Check In Date

* Check Out Date

* Guests are qualified to stay at Ronald McDonald House Charities of Greater Delaware, if their child is inpatient or being seen on an outpatient basis with appointments no more than 48 hours apart excluding weekends and official Holidays.

Guardian/Caregiver Information

* Guardian/Caregiver Name (First and Last)

Primary Phone Number

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity (for grant purposes only)

Preferred Language

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Ethnicity (for grant purposes only)

Address Information

Family Address:

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

Zip

Patient's Address (skip if same as family address):

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

State/Province

Zip

Additional Guest(s) Information

Will there be any additional guests staying at the House throughout your stay including children?

Additional Guests / Family Members: Add Another Guest

Total Number of Adult Guests:

Total Number of Children:

Additional Information

* Emergency / Additional Contact name

* Emergency / Additional Phone

Will your family require an ADA room? (our ADA rooms have a wheelchair accessible (roll-in) shower?

Will the patient or any family member have any sensory needs that may be supported during your stay?

What is you approximate household income?

(Note: Income information is strictly confidential and will only be used for funding purposes. Sharing this information helps us advocate for resources that better serve families)

Please submit a new background check if it has been 24 months or longer since your previous stay. Clicking on the "Submit Background Check Information" link will submit you room request.

By submitting this form I confirm that all of the information I have provided is true and I consent to RMHDE contacting the health system the patient is seeing to verify appointments, demographic information and any other information that may be necessary to determining my family's eligibility to stay at the House.