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Yes   No

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

Patient Information
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For Fetal Care patients please add patient as "Unborn" as first name.
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For Fetal Care patients please put your child’s expected date of delivery.
Patient Demographics
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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


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Hospital Stay Information
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

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Housing Request Details
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Insurance Details
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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
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Do you have secondary insurance through another provider, such as Kaiser, San Joaquin Valley, Health Net, etc.?
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Does family have a credit/debit card?
Yes No

Caregiver Information
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If preferred language is not listed, please list here:
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I agree to receive texts at this number.
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Can we contact you via text/email message?
Yes No

I agree to receive texts at this number.

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
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How many people usually live in your home, including yourself?
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Annual Household Income (Before Taxes)
 
What was the total combined gross income last year for you and the family members you live with?
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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
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In the last 12 months, did you ever worry that your food would run out before you got money to buy more?
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We have read and understood the guidelines of Ronald McDonald House at Stanford and agree to follow them.
Yes No

Special Accommodations Needed?
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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: 

Authorization

By submitting the information below, I agree to the authorization for exchange and release of information, allowing Ronald McDonald House to coordinate housing and support needs with my child’s hospital team or health plan, if applicable.

You will receive a copy of the release, and your Authorization signature panel below.
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Please list all patient(s) names related to this authorization:
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Print your name to sign
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Your Relationship to Patient
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Signature Date
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