Register To Stay - Ronald McDonald House Start Site

Have you stayed at RMHC of Marshfield in the past?*

Yes

In which year was your most recent stay at RMHC of Marshfield.*

Parent or Guardian Information

Parent/Guardian 1*

First Middle Last

Date of Birth*

Relationship to Patient*

Contact Phone Number*

Previous/Maiden Names

Previous State(s) of Residency

ID Upload

Drop files here or

Accepted file types: pdf, jpeg, png, Max. file size: 10 MB, Max. files: 5.

Upload a Photo of Your Driver's License or Government-Issued ID for each guest

Photo ID

I do not have a photo ID available at this time.

Do you wish to add a second Parent/Guardian?*

Yes

Parent/Guardian 2*

First Middle Last

Date of Birth*

Relationship to Patient*

Contact Phone Number

Previous/Maiden Names

Previous State(s) of Residency

ID Upload

Drop files here or

Accepted file types: pdf, jpeg, png, Max. file size: 10 MB, Max. files: 5.

Upload a Photo of Your Driver's License or Government-Issued ID for each guest

Photo ID

I do not have a photo ID available at this time.

Are any additional family members or supporters planning to stay overnight?*

Yes

Overnight Guests

Please tell us how many adults and children will be staying overnight on your first night at Ronald McDonald House. Only count guests who will be sleeping overnight. Daytime visitors do not need to be included.

Adults (18+) staying overnight:*

Children (Under 18) staying overnight:*

Name*

First Middle Last

Date of Birth*

Relationship to Parent/Guardian*

Name

First Middle Last

Date of Birth

Relationship to Parent/Guardian

Name

First Middle Last

Date of Birth

Relationship to Parent/Guardian

Patient Information

First Name*

Last Name*

Date of Birth*

Sex*

Male

Female

Ethnicity*

Facility*

Diagnosis*

Home/Mailing Address*

Street Address Address Line 2 City State ZIP Code

County*

Emergency Contact

Emergency Contact Name (Not staying at Ronald McDonald House)*

Emergency Contact Phone*

Relationship to Registrant

About Your Stay

Anticipated Arrival Date*

Anticipated Check-In Time*

Estimated Length of Stay*

Vehicle Make/Model/Color

Reserved guest parking is available next to the House near the Front Office entrance. Please park in any available reserved guest parking space.

I would like to utilize these additional services during my stay: (Select all that apply)

Health Screening

Please review the Health Screening Checklist before continuing.*

I have reviewed the Health Screening Checklist and confirm that I (and anyone staying with me) are currently free of any symptoms or exposures that would require notifying Ronald McDonald House before my stay.

I am unable to confirm this. Please contact me before my stay.

Optional Questions/Requests

Include any questions or requests that the House staff can address upon arrival.

House Policies & Guidelines Acknowledgment

To help ensure a safe, comfortable, and welcoming environment for all families, please review the Ronald McDonald House Policies & Guidelines before your stay.

Acknowledgment:*

I have read and understand the Ronald McDonald House Policies & Guidelines. I agree that I and everyone included in my reservation will follow these policies during our stay. I understand that failure to comply with House policies may affect my eligibility to remain at Ronald McDonald House.

Electronic Signature*

Guest Registration

Parent or Guardian Information

Overnight Guests

Patient Information

Emergency Contact

About Your Stay

Health Screening

Optional Questions/Requests

House Policies & Guidelines Acknowledgment

Acknowledgment:*

Ronald McDonald House Health Screening

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