Ronald McDonald House Southern New Jersey Online Room Request

Stay Request

Please enter your expected arrival date, all requests are honored but due to high demand you may be placed on a wait list. All guests 18 & over must complete a background check prior to approval. Ronald McDonald HouseSouthern New Jersey accommodations are for patients and immediate family/caregivers only. The Guest Services Manager will reach out to you between 10-1pm on the day of your expected arrival.

* Arrival Date

* Estimated Departure Date

Ronald McDonald House of Southern New Jersey and Ronald McDonald House Philadelphia 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 (856) 966-4663.

Who is completing this form?

Social Worker Name

Social Worker Phone

Social Worker Email Address

Patient Information
To add additonal 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 (MM/DD/YYYY)

* Patient Ethnicity

* Diagnosis

Patient is being treated at:

* Will the patient be inpatient or outpatient?

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

Guardian Information

* Guardian 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

I agree to receive texts at this number.

Alternate Phone

I agree to receive texts at this number.

* Email

* 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

State/Province

Zip

Guardian 2 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

I agree to receive texts at this number.

* Email

Additional Guest Information

Our rooms accomadate between 3 and 6 guests. Please add any additional family members who will be staying at Ronald McDonald House.

Additional Guests / Family Members: I agree to receive texts at this number.

Add Another Guest

TREATMENT INFORMATION

Transportation to Ronald McDonald House

Car Make/Model/Description

Car License State

License Plate#

I hereby agree and consent to allow Ronald McDonald House of Southern New Jersey to use all past, present, and future photos/videos for media/publicity purposes. I understand that my name and/or child’s name may be used. I agree and consent to allow Ronald McDonald HouseSouthern New Jersey to use those names with the photos taken/used.

Would you agree to undergo a background check?

If yes, please list the name(s) and the pertinent information:

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

If you would like a confirmation and copy of this request, enter your email address here.

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact E-Mail:

Is this family sponsored?

Shriner's Hospital Sponsor Name/Organization:

Shriner's Hospital Sponsor Contact Phone #:

Shriner's Hospital Sponsor Contact E-Mail: