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 stay paid for by IKF?
Is this paid for by Children's Life Fund Authority?


3. Guest Information- Who will be staying?

* Emergency Contact Name
* Emergency Contact Phone Number
* Emergency Contact Relationship


4. Additional Information

* Estimated Time of Arrival
Has family stayed before?
Main language?
* 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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