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Online Guest Stay Request

STAY WITH US

Guest Stay Request

It is our pleasure to provide you with a home away from home while you are staying with us. Heres what you can expect during your stay at the Ronald McDonald House:

One private bedroom per family (Room sizes vary, sleeping as many as 6 people. A limited number of roll-away beds and pack-n-plays are available.)

Private bath and shower facilities
Kitchen, laundry, and recreation facilities
TV lounge, reading room, outdoor porch grill, computer and internet access
Pantry items, fresh foods and prepared meals provided by the community
Friendly and supportive environment

Ronald McDonald House guests must be referred by a medical facility, social worker or designated nurse clinician and have a child 21 years of age or younger receiving medical treatment.

1. Stay Request

* Stay Location

* Arrival Date

* Expected Departure Date

* # Occupants First Night

Request completed by

2. Patient Information- Who is going to be the child receiving treatment?

If mother is a high-risk pregnancy patient, please enter mothers information here.

* First Name

Middle Name

* Last Name

* Gender

* DOB

* Ethnicity

* Diagnosis

Facility Treated At

Inpatient - Hospitalized

If Other, please include here

Insurance Provider

Medicaid

Blue Cross Blue Shield

Tri-Care or Other Military Benefits

Humana

Other

Add Another Patient

3. Guest Information- Who will be staying?

* First Name

Middle Name

* Last Name

* Gender

* DOB

* Relationship to Patient

* Email

Type of Email

* Cell Phone

* Home Phone

Type of Address

* Country

*County

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

Vehicle Information

* Vehicle Model

* Vehicle Make

* Military

Army

Air Force

Marines

Reserves

Navy

Retired

Not Military

Add Another Guest

4. Additional Information

The following question will not affect your ability to stay with us. Responses will be kept confidential and are only used to improve services and support fundraising efforts.

* Annual Income

Less than $25,000

$25,000-$40,000

$40,000-$100,000

* Do any of the individuals seeking to utilize RMHC services - have a travel history from abroad within the past 14 days?

YES

NO

* Does anyone staying in your room take medication that requires refrigeration?

Yes

No

* Have any of the individuals seeking to utilize RMHC services, knowingly had contact with a traveler who recently visited abroad within the past 14 days?

YES

NO

Enter additional guest information below, Full Name| Date of Birth:

By clicking yes, you verify you understand and agree to the following statements:

The patient receiving evaluation and/or treatment is 21 years of age or younger.

All guests staying at RMH are free of symptoms related to contagious illnesses.

I understand that RMHC-NWFL cannot guarantee my family a room.

Please use the background screening button for all guest over the age of 18 to complete the application process.

Background Screening

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Ronald McDonald House Charities
of Northwest Florida
5200 Bayou Boulevard
Pensacola, Florida 32503

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