* The patient receiving evaluation 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 guests ID's will be 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 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

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Family Contact Information

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* 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

Reservation Information

* Will the patient be inpatient or outpatient?

* Date of first appointment at hospital

* Check In Date

* Check Out Date

* Does the patient have Medicaid?

Medicaid if yes, brief description of what patient is being seen for

Medicaid Branch

Medicaid Id (if no medicaid, type N/A)

Additional Information for your stay

Will you have a vehicle on premises?

Car Make/Model/Description

Car License State

License Plate#

* 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?