New Family Request to Stay

Determination of Eligibility

Please answer the following questions to determine your eligibility to stay in a room at one of the Cherry Street Houses (Bernstein / Wylie / Longfellow).

Has the patient or patient's family stayed with Ronald McDonald House Charities of Kansas City in the past two (2) years?

This includes both an on-campus room in one of our Cherry Street Houses (Longfellow, Bernstein or Wylie), the House in the Hospital - Children's Mercy (former CMH Family Room), or in the Overland Park Family Room.

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

Do you or anyone in your guest party currently have an open case with any state child protection division and/or are under investigation by law enforcement for possible 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 (Captured for statistics only)

* Patient Ethnicity (Captured for statistics only)

Does the patient have Medicaid?

Medicaid Provider

Medicaid ID#

Patient's Primary Residence Address

Please use the patient's primary residence for this address.

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Guardian/Family Contact Information

Are you the primary caregiver of the patient?

* Parent or Guardian - First and Last Name

* Parent or Guardian - Date of Birth

* Parent or Guardian - Relationship to Patient

* Parent or Guardian - Gender (Captured for statistics only)

* Parent or Guardian - Ethnicity (Captured for statistics only)

* Primary Language

* Parent or Guardian - Email

* Parent or Guardian - Phone Number

I agree to receive texts at this number.

Second Parent or Guardian - First and Last Name

Second Parent or Guardian - Date of Birth

Second Parent or Guardian - Relationship to Patient

Second Parent or Guardian - Gender (Captured for statistics only)

Second Parent or Guardian - Ethnicity (Captured for statistics only)

Second Parent or Guardian - Email

Second Parent or Guardian - Phone Number

I agree to receive texts at this number.

Additional Overnight Guests

Please enter the total number of overnight guests checking in for this request to stay.

Standard rooms will sleep four (4) adults comfortably with a maximum of six (6) people including children and infants.

Foldable matresses may be available but are limited.
We may not be able to accommodate large numbers of family members for overnight stays.
Day passes and large common spaces are open and available.

Additional Overnight Guests / Family Members: Add Another Guest

Emergency / Additional Contact name

Emergency / Additional Phone

Request to Stay - Details

Please note the following when completing this section:

If the patient is staying overnight at the hospital or treatment location, please choose INPATIENT - HOSPITALIZED
If the patient is here for an appointment or same day procedure, please choose OUTPATIENT - NON-HOSPITALIZED
If the patient has both appointments AND will be staying overnight at the hospital or treatment location, please choose BOTH DURING THIS STAY

Requests are accepted starting 30 days prior to the desired check-in date, and continue to be accepted through to the day of check-in.

* Patient will be:

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

* Patient is being treated at:

* Department

Speciality

Inpatient Date / Outpatient Appointment

Requests are accepted starting 30 days prior to the desired check-in date, and continue to be accepted through to the day of check-in.

If the patient is currently inpatient in the hospital, select the date the patient was admitted.
If the patient has outpatient appointments, select the date of the appointment.

* Inpatient or Outpatient Appointment Date

Check-in Date

Please choose the date you would like to check into an RMHC-KC provided room.

Same day check-in requests are welcome but availability may be limited.

You can only request to check-in one (1) day prior to your appointment date chosen above.

* Check In Date

Is this for an Outpatient appointment or same day surgery without hospital admit?

* Check Out Date

Will you have a vehicle on premises?

Vehicle Make / Model / Color

License Plate#

Car License State

Acknowledgements and Permissions

Priority is given to families who live 35 miles or more away from where their child is receiving medical care. Only one (1) room per family.

We will do our best to fulfill your entire request however, due to room size and availability, we may not be able to accommodate your entire requested stay. Standard rooms will sleep four (4) adults.

To protect the health and safety of everyone on campus, all guests and visitors must be symptom-free (cough, fever, rash) of any contagious illness.

I give permission for staff/volunteers to forward my incoming calls to my room extension.

In some instances, RMHC-KC may need to contact the hospital to discuss the status of your stay at the house. I grant RMHC-KC staff permission to contact the hospital directly.

Comments / Additional Needs