Room Request RSVP Page for Ronald McDonald House of the Greater Hudson Valley

Your information

Attendees Attendees

Enter attendees

First name First name

Enter a first name

Last name Last name

Enter a last name

Phone Phone

Enter a phone number

Phone type Phone type

Email address Email address

Enter a valid email address

Email type Email type

Send me email updates & newsletters

Events

Monthly Newsletter

Volunteering

Address

Home Work

Address Address

Enter an address

Apartment, suite, etc. (optional) Apartment, suite, etc. (optional)

City City

Enter a city

Country/region Country/region

Enter a country

State State

Enter a state

ZIP code ZIP code

Enter a zip

Send me lettermail updates & newsletters

Additional details

Room Requests are submitted by families and will be reviewed by the staff at the House. If the staff determines that you/your family is eligible to stay at the House, you will be placed on our wait-list. Generally speaking, the wait-list is triaged by how critical the child's illness is and how far the family lives from the treatment hospital.

Patient Name Patient Name

Enter a response

Patient Date of Birth Patient Date of Birth

Enter a response

Unit of Hospital Unit of Hospital

Enter a response

Parent/Guardian 1 (Full Name) Parent/Guardian 1 (Full Name)

Enter a response

Parent/Guardian 2 (Full Name) Parent/Guardian 2 (Full Name)

Enter a response

Home Address (Street) Home Address (Street)

Enter a response

Home Address (Apt. No. or Other Additional Information) Home Address (Apt. No. or Other Additional Information)

Enter a response

Home Address (City, State and Zip Code) Home Address (City, State and Zip Code)

Enter a response

Contact Phone No. Contact Phone No.

Enter a response

Contact E-mail Contact E-mail

Enter a response

Relationship to the Patient Relationship to the Patient

Enter a response

Do you rely on public transportation? Do you rely on public transportation?

Enter a response

Will you have other children staying with you? Will you have other children staying with you?

Enter a response

In what region do you live? In what region do you live?

Enter a response

Would you like to use the House for the day or stay in a room overnight? Would you like to use the House for the day or stay in a room overnight?

Enter a response

If you wish to stay overnight, provide a requested start date and estimated end date. If you wish to stay overnight, provide a requested start date and estimated end date.

Enter a response

Who referred you to our House? Who referred you to our House?

Enter a response

If referred by a hospital, provide the name and phone number of social worker/hospital employee who referred you. If referred by a hospital, provide the name and phone number of social worker/hospital employee who referred you.

Enter a response

Have you or anyone asking to stay with us stayed at a Ronald McDonald House before? Have you or anyone asking to stay with us stayed at a Ronald McDonald House before?

Enter a response

If anyone asking to stay has stayed at a House before, provide the name of the House and dates of the stay. If anyone asking to stay has stayed at a House before, provide the name of the House and dates of the stay.

Enter a response

Documents

Complete_Referral_Paperworkl.pdf

Confirmation

Click Continue to review our terms and conditions

Continue