HOSPITAL STAFF ROOM REQUEST FORM

The Ronald McDonald House of the Philadelphia Region requires all NEW families have a room request submitted by the hospital their child is visiting.

Please review our Eligibility Requirements, House Guidelines & Rules, and FAQ before submitting a room request.

BY SUBMITTING A ROOM REQUEST YOU ARE ACKNOWLEDGING THAT YOU UNDERSTAND THE FOLLOWING:

ELIGIBILITY: Submitting an application does not guarantee that a family is eligible to stay or that a room is available.

THIS IS NOT A RESERVATION: The Room Request you are about to submit is not a reservation. On the day of the requested arrival, the Family Services department will contact the family between 10:30 AM and 1 PM to inform them of their room request status. Families will receive an EMAIL if there are no rooms available. Families will receive a CALL if a room is available.

MAKING ALTERNATIVE ARRANGEMENTS: We strongly encourage all families to make a backup plan in the event that we are unable to accommodate them as we are typically at capacity. A discount hotel list is attached to the acknowledgment email we send once their request is processed.

BACKGROUND CHECKS: All caregivers, patients, and guests 18 and older must complete and clear a criminal background check prior to their stay. We reserve the right to deny entry to those whose criminal records may jeopardize the health, safety, and welfare of the House. We value honesty and transparency when discussing the contents of a criminal background check.

For updates or questions regarding room requests, please email Family Services at RoomRequests@philarmh.org or call us at 267-969-6220. Family Services is open 7 days a week from 9 AM to 5 PM.

* Denotes a required field

RMHC Philadelphia and RMH of Southern New Jersey work together to serve the Philadelphia region and utilize a shared database system to ensure that families are served efficiently. Please acknowledge that you have confirmed the family’s understanding and consent that all information entered into the room request form below will be available to both organizations. If you have questions before proceeding, please do not hesitate to call us at (267) 969-6220.

HOSPITAL REQUESTOR INFORMATION

* Your Name

* Phone

PATIENT INFORMATION
To add an additional patient, use the additional guest block below and select "patient" under the relationship field.

* Patient Name ( First and Last )

Has Patient been vaccinated for measles, mumps, and rubella (MMR), and been vaccinated for and/or diagnosed with chickenpox in the past? All guests must be up to date on MMR vaccinations unless medically exempt with signed documentation from a physician.

* Patient Gender

* Patient Date of Birth (or delivery date if unborn)

* Primary Language

PATIENT/GUARDIAN ADDRESS
Families are qualified to stay if they live 25 miles or more from the House

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

GUARDIAN INFORMATION

* Guardian/Caregiver Name

Has Guardian 1 been vaccinated for measles, mumps, and rubella (MMR), and been vaccinated for and/or diagnosed with chickenpox in the past? All guests must be up to date on MMR vaccinations unless medically exempt with signed documentation from a physician.

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Primary Phone Number

Second Guardian/Caregiver Name

Has Guardian 2 been vaccinated for measles, mumps, and rubella (MMR), and been vaccinated for and/or diagnosed with chickenpox in the past? All guests must be up to date on MMR vaccinations unless medically exempt with signed documentation from a physician.

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

* Relationship to patient

Primary Phone Number

ADDITIONAL ROOM OCCUPANTS
Please note that each room can only accommodate up to 4 individuals.

Additional Guests / Family Members: Add Another Guest

TREATMENT INFORMATION

* Date of Admission or First Appointment During Requested Stay

* Requested Check In Date

Expected Check Out Date

* Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

* Diagnosis (If unlisted, please specify in the note section)

* Brief Description of Treatment (Follow-up appointment, inpatient surgery, etc.)

* Hospital in Philadelphia

* Hospital Department (e.g. Oncology, Cardiology, Neonatology)

Treating Doctor

Treating Doctor's Phone Number

Assigned Social Worker / Hospital Staff

Hospital Social Workers Phone Number

ADDITIONAL INFORMATION

Is anyone staying at the House:

A Wheelchair User
Visually Impaired
Deaf/Hard of Hearing
Dependant on Electronic Equipment

Does anyone in the family have a service animal?

No Yes

If yes, please provide the name of the service dog and the type of service it provides. Please note: Proof of rabies vaccination is required prior to arrival.

Special Requests (e.g. wheelchair access, pack-n-play)

Additional Room Request Notes

If you would like a receipt for this request, enter your email address below: