Guest Stay Request

1. Stay Request

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

If premature, how many weeks gestation was baby?
Insurance Provider
* Medicaid Plan Name
Patient Insurance Member ID #
If Other, please include here

3. Guest Information- Who will be staying?

Do not text my mobile number

* Annual Income (2021)
* Employment
* Military Base

4. Additional Information

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

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


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

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

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


heartTo help the Ronald McDonald House continue to serve families in need, please consider a donation of $10 per night. If your child has a Medicaid health plan, your stay may be reimbursed to RMHC.


You may also donate to the Guest Families Fund using the QR code in your guest room or share it with family and friends.


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