WELCOME

By submitting a room request, you acknowledge that you have reviewed and understand our eligibility requirements.
*
¿Se ha alojado en RMHC Kentuckiana en los últimos 30 días?
*
¿Vive en el condado de Jefferson, KY, o en los condados de Floyd/Clark de Indiana?
*
Will any guest staying at the House have an open Child Protective Services case?
*
I am aware that even if my childs appointment is in the afternoon, checkout time is 11am.

PATIENT INFORMATION

To add additional patient(s), enter the information in the additional guest’s section below and select the ‘patient’ relationship.
*
*
*
*
*
*
*
Paciente Interno- Hospitalizado   Paciente Externa- No Hospitalizado   Ambos, durante esta estancia.

*
Patient is being treated at:
*

*
Appointment time
*


GUARDIAN CONTACT INFORMATION
*
*
*
Acepto recibir mensajes de texto en este número.
You will receive a text from SlickText, please respond YES to opt in. Standard messages and data rates apply.
Búsqueda postal de EE. UU. / Canadá


*
*
*
Acepto recibir mensajes de texto en este número.

ADDITIONAL GUEST(S) INFORMATION
 
Will there be any additional guests at the House throughout your stay? Please enter their information below (siblings, grandparents, service animals, etc).
Invitados adicionales / miembros de la familia

Agregar otro invitado

Demographic Questions

The following questions will only be used for reporting purposes.
Is anyone staying at Ronald McDonald House Louisville a veteran?
Please list the place of employment for each guardian:
Guardian One Employer:
Guardian Two Employer:

Additional Information
*
*
*
Will you have a vehicle in Louisville? Parking is limited at the House. Your family may need to park at the Hospital during your stay. The Chestnut Street parking lot is only for families that need ADA access.
No   Yes
*
*
Does the family require ADA accommodations?
*
Does anyone in the family have any food allergies? If yes please list their name, age, and the allergy.

*
Guardian 1 Electronic Signature:
AFTER COMPLETING THIS FORM, PLEASE GO BACK AND COMPLETE THE REGISTRATION FORMS ALSO, THANK YOU
Guardian 2 Electronic Signature: