Request a Room at Ronald McDonald House

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

* 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

* Ethnicity: for statistics only

* 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

* 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

* 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?