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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

* Estimated 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

* Date of Birth

* Ethnicity

* Diagnosis

Facility Treated At

If premature, how many weeks gestation was baby?

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

* Date of Birth

* Relationship to Patient

* Email

Type of Email

Home Phone

* Mobile Phone

By providing your mobile number you agree to get occasional text messages from our organization. If you do not want to receive text messages check here:

Do not text my mobile number

Type of Address

* Country

*County

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

Vehicle Information

* Vehicle Model

* Vehicle Make

COVID-19 Information

Vaccination Status

* Have you had a new skin rash within the last four (4) weeks?

Yes

No

* Annual Income (2021)

Less than $25,000

$25,000-$32,600

$32,600-$52,150

$52,150-$65,200

$65,200 and above

* Employment

* Military Base

Eglin AFB

Hurlburt AFB

Tyndall AFB

Other Base

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.

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

Yes

No

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.

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

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