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    Please complete the form below to attend.

    1. How many people in your party attending?

    2. If this campaign is a physical event, the organization may need to contact you. Please provide your info below.

    Additional Info.

    Please review the information and complete this form.

    1. 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.
      1. Patient Name *
      2. Patient Date of Birth *
      3. Unit of Hospital *
      4. Parent/Guardian 1 (Full Name) *
      5. Parent/Guardian 2 (Full Name)
      6. Home Address (Street) *
      7. Home Address (Apt. No. or Other Additional Information) *
      8. Home Address (City, State and Zip Code) *
      9. Contact Phone No. *
      10. Contact E-mail *
      11. Relationship to the Patient *
      12. Do you rely on public transportation? *
      13. Will you have other children staying with you? *
      14. In what region do you live? *
      15. Would you like to use the House for the day or stay in a room overnight? *
      16. If you wish to stay overnight, provide a requested start date and estimated end date. *
      17. Who referred you to our House? *
      18. If referred by a hospital, provide the name and phone number of social worker/hospital employee who referred you.
      19. Have you or anyone asking to stay with us stayed at a Ronald McDonald House before? *
      20. If anyone asking to stay has stayed at a House before, provide the name of the House and dates of the stay.

    The Home Stretch.

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    I understand that by agreeing to the terms of this request the Ronald McDonald House will contact the treating hospital to verify the information I have submitted. I allow Ronald McDonald House to contact hospital personnel in order to verify the information I have submitted. I understand that if I do not agree to this, my request will not be submitted for review.


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