Request to stay for Children's Mercy ICU Families

To stay at Ronald McDonald House, while you have a patient in the ICUs, we ask that you meet the following criteria:

* I have a patient in one of Children's Mercy Hospital (CMH) ICUs (PICU, NICU, or Cardiac ICU).

Please note that this form is for families that have children in the ICUs that live less than 35 miles away from CMH. If your family does not meet these critera, please click here to fill out a request link.

* The patient receiving evaluation, care and/or treatment is 21 years of age or younger?

* Do any members of the guest party have symptoms related to contagious illnesses?

* 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?

* Are you or anyone in your guest party listed on the National Sex Offender Registry? NOTE: all guest ID's are scanned upon arrival

* Have you or anyone in your guest party been convicted of or are currently facing charges for a felony or violent criminal offense?

Patient Information

* Patient Name ( First and Last )

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

* Patient Gender

* Primary Language

* Patient Ethnicity

* Patient is being treated at:

Diagnosis

* Department

Patient's Primary Address
Has the Patient's home address changed since your last stay?

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Guardian/Family Contact Information

Please note that the room can only accommodate two adults.

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Email

* Primary Phone Number

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Date of Birth (MM/DD/YYYY)

Primary Phone Number

Ethnicity

* Date of first appointment at hospital

* Check In Date

Check Out Date

* I understand that once I check-in to RMHC-KC that my stay will be three (3) days. If you need an extension, please email: Stay@rmhckc.org

* Does the patient have Medicaid?

Medicaid Branch

Brief description of what patient is being seen for

Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the patient’s family.

Emergency / Additional Contact name

Emergency / Additional Phone

Does anyone in the guest party need a wheelchair accessible room?

* I certify that the above information is true and correct.

Any additional information you would like to add?