Go to the Ronald McDonald House Charities of Kansas City website.
Online Request
*
To complete this request, you must have previously stayed at RMHC-KC in the past three years.
Please contact your hospital medical provider or hospital social worker if you need a request completed for a new guest
stay
.
Please select a response
No
Yes
Please reach out to your child's medical team to send RMHC-KC a referral. If you have questions, you can reach us at 816-541-8460.
*
I understand that a room may not be available on the date of the requested check-in due to availability. Please call 816.541.8460 on your day of requested check-in.
Yes, I understand.
*
The patient receiving evaluation, care and/or treatment is 21 years of age or younger?
Please select a response
No
Yes
Unfortunately, the family is not eligible to stay at RMHC-KC.
Exeptions to the following can be made:
Mother is the patient
and
receving Fetal Healthcare in the Kansas City Metro area.
Please change your response to Yes and continue the form with Baby listed as the patient.
Patient is over 21
and
receiving care at Children's Mercy Hospital.
*
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 guest ID's are 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
You may continue to complete and submit this current request to stay even if the answer is yes.
However
, a
Felony Exception Request
must be
submitted for Committee review and approved
before
that person will be eligigiable to stay in an on-campus RMHC-KC provided room. It is reccommended that the person with the conviction complete the
Felony Exception Request
.
Patient Information
*
Patient Name ( First and Last )
*
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*
Patient Vaccination Status
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Prefers not to answer
*
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Nonconforming
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*
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*
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Please select a response
No
Yes
Please enter Medicaid information below.
Please skip Medicaid Questions below.
Medicaid Branch
MO Anthem Healthy Blue
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Medicaid Id (if no medicaid, type N/A)
Brief description of what patient is being seen for
*
Date of first appointment at hospital
*
Will the patient be inpatient or outpatient?
Inpatient - Hospitalized  
Outpatient - Non-Hospitalized  
Both, during this stay.
*
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
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Cystic Fibrosis
Dental Clinic
Dermatology
Down Syndrome
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Liver Transplant
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NICU-Newborn Intensive Care
Occupational Therapy and Physical Therapy
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Pulmonary
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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
*
Diagnosis
*
Check In Date
*
Check Out Date
*
Patient is being treated at:
Ability KC
Advent Health Center - Shawnee Mission
Camber Children's Mental Health - formerly KVC
Children's Mercy Hospital - Adele Hall
Children's Mercy Hospital - Kansas
Cornerstones of Care - Spofford Campus
EDCare Kansas City
Kids TLC
Menorah Medical Center
North Kansas City Hospital
Overland Park Regional Medical Center
Research Medical Center
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Other
*
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Please select a response
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Family Contact Information
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*
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*
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That's good.
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*
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*
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*
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*
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*
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Add Another Guest
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.
*
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*
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Additional Information for your stay
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*
Will you have a vehicle on premises?
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Please include the vehice information below.
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*
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Does anyone in the guest party need a wheelchair accessible room?
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Yes
*
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