Ronald McDonald House Family Room Request Form

To be completed and submitted by social workers only. Please provide all information requested. Before filling out this application, please keep in mind patient's must live at least 50 miles from St. Louis.

Social Worker Information

Social Worker

Contact Person

Contact Number

Contact E-mail

Patient and Guest Information

First Day of Need

Estimated Length of Stay

Last Name

First Name

Gender

Patient's Birth Date

Patient Age

Patient's Phone Number

Patient's Street Address

City

State

Postal Code

Guest's Name

Guest's DOB

Relationship to Patient

Second Guest Name

Second Guest DOB

Second Guest Relationship to Patient

Third Guest Name

Third Guest DOB

Third Guest Relationship to Patient

Fourth Guest Name

Fourth Guest's DOB

Fourth Guest Relationship to Patient

Hospital

Department

Phone

Email Address

Number of Adult Guests

Number of Child Guests

No one under 18 may stay at the House without a parent/guardian

Special Needs

Wheelchair Access

Crib

None

Other (Please Specify)

Is anyone in the room immunosuppressed?

Yes

No

Does the family have transportation?

Yes

No

Other

By submitting this form the requesting social worker accepts responsibility for understanding the Ronald McDonald House Occupancy and Room Request Guidelines and has confirmed that this family meets the requirements for temporary lodging at the RMH. All requests will be placed on the Waiting List in the order received.

When a room becomes available, the Guest, Social Worker, or Contact Person listed above will be notified. If a family has been offered a room and they decline, their room referral needs to be resubmitted for them to be put back on the list. Requests are taken no earlier than 3 working days in advance of first day of need, which includes the first day of need.

For Monday – Submit on Thursday
For Thursday – Submit on Tuesday
For Tuesday – Submit on Friday
For Friday – Submit on Wednesday
For Wednesday – Submit on Monday

To check on a room request previously, call (314) 531-6601, ext. 1204 or e-mail jbraucksieker@rmhcstl.com.

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