Complete your online request and click on SUBMIT.

1. Stay Request

2. Patient Information

* 1. Name of Person Making Referral
* 2. Title of person making referral
* 3. Phone number of person making referral
4. Email address of person making referral
* Physician
* Refer Agency

3. Guest Information

* 1. Is there any reason the guest would not be appropriate for Ronald McDonald House?
* 2. Does the guest have a current Child Protective Services investigation or previous conviction?
* 3. Is the guest a registered sex offender or currently under investigation for a sex-related crime?
* 4. Is the guest under investigation for or previously convicted of a violent offense?
* 5. Does the guest have any current pest infestation? If so, guest is not eligible for admission
* 6. Is the guest a carrier of any infectious illness? If so, guest may not be eligible for admission. Please detail below.

4. Additional Information

* 1. Has the family tested positive for COVID-19?
* 2. Has the family been around anyone with confirmed or suspected COVID-19?
* 6. Does the family agree to wear masks, wash hands frequently, maintain social distancing, submit to temperature checks, and other COVID-19 related requirements?

Notes regarding this request:

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