Guest Family Housing Request

* Have you stayed with us before?

Yes No

Have you stayed at another Ronald McDonald House location? Where?

Patient Information

* Patient Name

For Fetal Care patients please add patient as "Unborn" as first name.

* Patient Date of Birth (MM/DD/YYYY)

For Fetal Care patients please put your child’s expected date of delivery.

Patient Gender

Patient Vaccination Status

Patient Demographics

Is the patient Hispanic, Latino/a, or Latinx?

How would you describe your patient's race?

If you selected 'Other', please describe:

Patient Address

Begin by entering your zip code in the first field. This will automatically populate your city, county, and state.

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Hospital Stay Information

* Patient is being treated at:

Department

* Diagnosis

* Will the patient be inpatient or outpatient?

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

Assigned Social Worker / Hospital Staff

Physician/Doctor

* Date of First Appointment at the Hospital

Housing Request Details

* Requested RMH Check In Date

* Estimated RMH Check Out Date

Insurance Details

Does the patient or family have health insurance?

If you have insurance, please provide the following information in the box below and contact your provider to request a lodging pre-authorization.

Insurance Provider Name
Medical ID Number
Phone Number On Your Insurance Card

Do you have secondary insurance through another provider, such as Kaiser, San Joaquin Valley, Health Net, etc.?

Does family have a credit/debit card?

Yes No

Caregiver Information

* Guardian Name

* Relationship to patient

Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Primary Language

If preferred language is not listed, please list here:

* Primary Phone Number

I agree to receive texts at this number.

Can we contact you via text/email message?

Yes No

Second Guardian Name

Relationship to patient

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Primary Phone Number

I agree to receive texts at this number.

Emergency / Additional Contact name

Emergency / Additional Phone

Guests

Number of Adults Staying

Number of Children Staying

Additional Guests / Family Members: Add Another Guest

Additional Family Information

Family’s method of transportation to the hospital or our house?

Do you have a vehicle with you (personal / rental)?

Yes No

How many people usually live in your home, including yourself?

Annual Household Income (Before Taxes)

What was the total combined gross income last year for you and the family members you live with?

We give Ronald McDonald House Bay Area permission to use any photos, artwork, or video’s taken/created including child’s first name, age and diagnosis.

Yes No

In the last 12 months, did you ever worry that your food would run out before you got money to buy more?

We have read and understood the guidelines of Ronald McDonald House at Stanford and agree to follow them.

Yes No

Special Accommodations Needed?

Is everyone able to do stairs?

Are there any special needs for your family? (wheelchair, breast pump, fridge, freezer, pack n play, etc.). If yes, please describe below.

Can family be contacted via text/email message?

Yes No

Do you require lodging financial assistance?

Are there any contact isolation precautions for the patient or anyone in your family that will be staying at the House? If yes, please explain.

Anything else?

Please share additional details that you'd like our Ronald McDonald House team to know about your family or this housing request below: