1. Stay Request



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

* Medical Department
Insurance Provider
* Medicaid Plan Name
Patient Insurance Member ID #
If Other, please include here
* Is this Guest Stay Funded By:


3. Guest Information- Who will be staying?

Contact Information

 I accept to receive text messages on this number
* Emergency Contact Name
* Emergency Contact Phone Number
* Emergency Contact Relationship


4. Additional Information

* Main Speaking language
* Family Income - Answering this question does not affect the status of your stay
* Is this family International or Domestic?
Has family stayed before?
* Vehicle on premises?

Any special request or need, please write below:





Your application has been received.

The information provided in this application has consent of the individuals for the sole purpose of referral information for temporary lodging at Ronald McDonald House Charities of South Florida.  This information is confidential and may not be used, published or redistributed at any time without prior consent of the individuals.  

 

For any questions, feel free to give us a call at 305-324-5683.

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