RMH SNJ Online Room Request

Ronald McDonald House Southern New Jersey

Stay Request
Please enter your expected arrival date. All families must complete a background check prior to approval. The Guest Services Manager will reach out to you no more than 72 hours before your expeceted arrival. Please note, confirmation of your check-in must be approved by the Guest Services Manager prior to arrival.

* Arrival Date

* Estimated Departure Date

RMH of Southern New Jersey and RMHC 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

Alternate Phone

* 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

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

* Email

Additional Guest Information

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

Additional Guests / Family Members: Add Another Guest

TREATMENT INFORMATION

Transportation to RMHC

Car Make/Model/Description

Car License State

License Plate#

I hereby agree and consent to allow Ronald McDonald House of SNJ 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 RMHSNJ to use those names with the photos taken/used.

Would you agree to undergo a background check?

Additional Room Request Notes

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.