Online Guest Stay Request


1. Stay Request


2. Patient Information





3. Guest Information



* A. What is your age?

* B. I am a first-time parent.

* C. What is your marital status?

* D. What is your current employment status?

* E. What is your highest level of education completed?

* F. What is your household income?

* G. Do you have Medicaid?

* H. Are you eligible for any other federal assistance (WIC, SNAP, SSI)?

* I. Will you require the hospital shuttle service?

* J. Who is your emergency contact?

* K. What is your emergency contact's phone number?

* L. Where would you stay if you were unable to stay at the Ronald McDonald House?



4. Additional Information


Notes regarding this request:




Acceptance

Your request will be processed. Do you want to continue?



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