Go to the Ronald McDonald House Charities of Kansas City website.
Reservation for Ronald McDonald House - Kansas City
To stay at Ronald McDonald House, you must meet the following criteria:
*
The patient receiving evaluation and/or treatment is 21 years of age or younger?
Please select a response
No
Yes
Unfortunately, you are not eligible to stay at RMHC-KC
*
Do any members of the guest party have symptoms related to contagious illnesses?
Please select a response
No
Yes
Unfortunately, you are not eligible to stay at RMHC-KC
*
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?
Please select a response
No
Yes
Unfortunately, you or a member of your guest party are not eligible to stay at RMHC-KC.
*
Are you or anyone in your guest party listed on the National Sex Offender Registry? (Note all guests ID's will be scanned upon arrival)
Please select a response
No
Yes
Unfortunately, you or a member of your guest party are not eligible to stay at RMHC-KC.
*
Have you or anyone in your guest party been convicted of or are currently facing charges for a felony or violent criminal offense?
Please select a response
No
Yes
The person with a felony conviction will need to fill out this form. The request can be filled out even if the answer is yes.
Felony Exception Request
*
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 availability, we may not be able to accommodate your entire requested stay.
Please select a response
Yes, I understand
Patient Information
*
Patient Name ( First and Last )
*
Patient Date of Birth (MM/DD/YYYY)
*
Patient Gender
Male
Female
Nonconforming
Primary Language
English
Arabic
Awadhi
Azerbaijani, South
Bengali
Bhojpuri
Burmese
Chinese, Gan
Chinese, Hakka
Chinese, Jinyu
Chinese, Mandarin
Chinese, Min Nan
Chinese, Wu
Chinese, Xiang
Chinese, Yue(Cantonese)
Dutch
French
German
Gujarati
Hausa
Hindi
Italian
Japanese
Javanese
Kannada
Korean
Maithili
Malayalam
Marathi
Oriya
Panjabi, Eastern
Panjabi, Western
Persian (Farsi)
Polish
Portuguese
Romanian
Russian
Serbo-Croatian, Serbian, Coation, Bosnian
Sindhi
Spanish
Sunda
Tamil
Telugu
Thai
Turkish
Ukrainian
Urdu
Vietnamese
Yoruba
Karen
Hungarian
ASL American Sign Language
Other
Chuukese
Nepali
*
Ethnicity (Captured for statistics only)
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
*
Patient is being treated at:
Ability KC
Baptist Medical Center
Camber Kansas City( KVC)
Cancer Treatment Center
Children's Mercy Hospital
CMH Kansas
EDCare Kansas City
Heartland Spine & Specialty Hospital
Hyperbaric Healing Institute
KC Children's Surgery Center
Kids TLC
KU Medical Center
Lakemary Center
Marillac
Menorah Medical Center
North Kansas City Hospital
Overland Park Regional Medical Center
Research Medical Center
Shawnee Mission Medical Center
Spofford
St. Luke's
SurgiCenter of Kansas City
Truman Medical Center
UMKC School of Dentistry
Other
Diagnosis
*
Department
Behavioral and Developmental
Allergy, Asthma and Immunology
Autism Clinic
Blood and Marrow Transplant
Bone and Mineral Disorder Clinic
Bone Marrow Transplantation Immune Deficiency
Bronchology
Burn Unit
Cardiology
Coronary Care Unit
Craniofacial Center
Cystic Fibrosis
Dental Clinic
Dermatology
Down Syndrome
Ear Nose and Throat
Emergency Department
Endocrinology
Eosinophilic Disorders
Epilepsy Center
Fetal Cardiac Clinic
Fetal Care Center
Gastroenterology
General Pediatrics
Genetics
Genomic Medicine
Gynecology
Headache Relief Clinics
Heart Transplant
Hematology
Hematology/ Oncology
Kidney Transplant
Liver Transplant
Nephrology
Neurology
NICU-Newborn Intensive Care
Occupational Therapy and Physical Therapy
Ophthalmology and Optometry
Orthopedic
Otolaryngology Head and Neck Surgery
Outpatient
Pain Management
Palliative Care
Pharmacology and Toxicology
Physical and Occupational Therapy
PICU-Pediatric Intensive Care Unit
Plastic and Reconstructive Surgery
Plastic Surgery
Pulmonary
Radiology and Medical Imaging
Rehabilitation
Rehabilitation for Amplified Pain Syndromes (RAPS) Program
Rheumatology
Same Day Surgery
Sleep Disorder
Small Bowel Liver Pancreas Transplant
Special Care Clinic
Special Immunology Clinic
Speech Pathology
Spinal Differences Clinic
Surgical Weight Loss
Thoracic Surgery
Thyroid Nodule and Carcinoma Clinic
Tourette Syndrome Center
Transplant Center
Type 2 Diabetes Prevention Clinic
Urology
Vascular
Velopharyngeal Dysfunction Clinic
Other
Patient's Primary Address
U.S. / Canadian Postal Code lookup
*
Country
--Select--
USA
Afghanistan
Aland
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos [Keeling] Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar [Burma]
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Minor Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
*
Address
City/Villa/Town
County/District
State/Province
State/Province
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
Zip
Family Contact Information
*
Guardian/Caregiver Name (First and Last)
*
Relationship to patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
Legal Guardian
Foster Parent
*
Guardian/Caregiver Gender
Male
Female
Nonconforming
*
Date of Birth (MM/DD/YYYY)
*
Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
*
Email
*
Primary Phone Number
Second Guardian/Caregiver Name (First and Last)
Relationship to patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
Legal Guardian
Foster Parent
Guardian/Caregiver Gender
Male
Female
Nonconforming
Date of Birth (MM/DD/YYYY)
Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
Primary Phone Number
Additional Guests
Additional Guests / Family Members
Add Another Guest
Reservation Information
*
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?
Please select a response
No
Yes
Please enter Medicaid information below.
Please skip Medicaid Questions below.
Medicaid if yes, brief description of what patient is being seen for
Medicaid Branch
MO-Anthem Healthy Blue
Kansas Aetna
Kansas United
Kansas Sunflower State
Missouri Healthnet
Missouri Home State Health
Missouri United
Medicaid Id (if no medicaid, type N/A)
Additional Information for your stay
Will you have a vehicle on premises?
Please select a response
No
Yes
Please include the vehice information below.
Please select/type NA for the questions below.
Car Make/Model/Description
Car License State
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
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?
Please select a response
No
Yes
*
I certify that the above information is true and correct.
Any additional information you would like to add?
Help Request Sent
Ok
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
Submit