Rejuvenation Room Daily Registration

Ronald McDonald House of the Greater Hudson Valley

* Patient Name ( First and Last )

Patient is being treated at:

* Department

Neighborhood? (If located in general pediatrics at MFCH.)

Room Number (If unknown, type N/A)

Assigned Social Worker / Hospital Staff

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

* Guardian/Caregiver Name (First and Last)

Relationship to patient

Primary Phone Number

I agree to receive texts at this number.

Who else will be joining you to use the Day Program?

* What Date would you like to use the Rejuvenation Room?

Would you like to use the room in the morning (9am-12pm) or afternoon (2pm-5pm)?