Request a Room at Ronald McDonald House

To stay at Ronald McDonald House, you must meet the following criteria:

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

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 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?

Priority is given to families who live 35 miles or more away from where their child is receiving medical care.

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.

Patient Information

* Patient Name ( First and Last )

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

* Patient Gender

* Primary Language

* Ethnicity: captured for statistics only

* Patient is being treated at:

* Diagnosis

* Department

Patient's Primary Address
Please provide the home address of the patient.

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Guardian/Family Contact Information

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity (Captured for statistics only)

* Email

* Primary Phone Number

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Ethnicity

Primary Phone Number

Additional Guests

Additional Guests / Family Members: Add Another Guest

Request to Stay - Details

* Will the patient be inpatient or outpatient?

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

* Date of first appointment at hospital

* Check In Date

* Check Out Date

Does the patient have Medicaid?

Medicaid Branch

Medicaid ID#

Brief description of what patient is being seen for

Additional Information

Will you have a vehicle on premises?

Car Color - Make - Model

Car License State

License Plate#

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?