Please complete all required information prior to submission. 
All stay requests must be confirmed by a staff member prior to arrival.


1. Stay Request
 
*

*

*

*
# Occupants First Night
*
Have any of the adults been convicted of child abuse or domestic violence or does anyone have an open DCF case?
 
*
Does every member of the family have a photo ID?
*
Will the family need transportation?

2. Patient Information
Additional Patients can be added in the guest information below. Select the relationship patient.
*
*
*
No   Yes
*
*
*
*
Reason for Visit (surgery/procedure, testing/imaging, outpatient/inpatient treatment, trauma care, etc.)
*
Referral Source
*
*
*
*
Has the Patient been exposed to any infectious or contagious disease?
*
Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

Additional Information:

3. Guest Information
*
*
I agree to receive texts at this number.
I agree to receive texts at this number.
U.S. / Canadian Postal Code lookup


*
*



*
*
*
*
*
I agree to receive texts at this number.



Additional Guests / Family Members

Add Another Guest

4. Additional Information
Billing
While Ronald McDonald House Jacksonville does not charge a fee or ask families to pay for their stay, we do work closely with Medicaid and other third-party partners to obtain lodging reimbursements for eligible family stays. This funding helps Ronald McDonald House ensure families can stay at no cost.
*
*
Does patient have Medicaid?
*
*
Medicaid Plan Name
*
*
Name:
Notes:
Email:
Address to send invoice (third-party only):