WELCOME

By submitting a room request, you acknowledge that you have reviewed and understand our eligibility requirements.
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Have you stayed at Ronald McDonald House Louisville in the last 30 days?
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Do you live in Jefferson County KY, or Floyd/Clark Counties of Indiana?
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Will any guest staying at the House have an open Child Protective Services case?

PATIENT INFORMATION

To add additional patient(s), enter the information in the additional guest’s section below and select the ‘patient’ relationship.
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

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Patient is being treated at:
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Appointment time
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GUARDIAN CONTACT INFORMATION
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I agree to receive texts at this number.
You will receive a text from SlickText, please respond YES to opt in. Standard messages and data rates apply.
U.S. / Canadian Postal Code lookup


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I agree to receive texts at this number.

ADDITIONAL GUEST(S) INFORMATION
 
Will there be any additional guests at the House throughout your stay? Please enter their information below (siblings, grandparents, service animals, etc).
Additional Guests / Family Members

Add Another Guest

Demographic Questions

The following questions will only be used for reporting purposes.
Is anyone staying at Ronald McDonald House Louisville a veteran?
Please list the place of employment for each guardian:
Guardian One Employer:
Guardian Two Employer:

Additional Information
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Will you have a vehicle in Louisville? Parking is limited at the House. Your family may need to park at the Hospital during your stay. The Chestnut Street parking lot is only for families that need ADA access.
No   Yes
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Does the family require ADA accommodations?
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Does anyone in the family have any food allergies? If yes please list their name, age, and the allergy.

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Guardian 1 Electronic Signature:
Guardian 2 Electronic Signature: