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RMHC Richmond Request a Room Form

Please print and fax to 804.358.3153
or submit online below.

A staff member will contact you to complete your request.
Please call 804.355.6517 if you do not receive a response within
2 hours of completing this request.

Stay Information

Today's Date *
Date of Arrival *
Length of Stay *

Number of Guests

Adult Guests *
Children Guests *

Patient Information

Patient Name *
DOB (Must be 21 or younger) *
Gender *
MaleFemale
Referring Unit *
Hospital *
Diagnosis *
Physician *
Referring Staff Member Name & Title *
Staff Phone Number *
Staff Email *

Primary Guest Information

Parent/Guardian Name *
Phone Number *
Relationship to Patient *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Other Parent/Guardian Name
Cell/Alternate
Relationship to Patient

Additional Guest Information

Guest #1

Name
Age
Relationship to Patient

Guest #2

Text
Name
Age
Relationship

Guest #3

Name
Age
Relationship
Does the family need transportation? *
Do any guests have any physical limitations that would prevent them from climbing stairs? *

Verification

Please enter any two digits *Example: 12
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© RMHC
• 2330 Monument Avenue, Richmond, VA 23220 • Phone: 804.355.6517 • Fax: 804.358.3153

The following trademarks used herein are owned by RMHC and its affiliates; McDonald's, Ronald McDonald House Charities, Ronald McDonald House Charities Logo, RMHC, Ronald McDonald House, Ronald McDonald Family Room, and Ronald McDonald Care Mobile.

RMHC Richmond is recognized as a public charity under Internal Revenue Code section 509(a) and has 501(c)(3) status. Donations to RMHC Richmond are deductible. Donors should consult their tax advisor for questions regarding deductibility. The RMHC EIN is 52-1359486. A copy of the RMHC Richmond determination letter is available upon request.

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RMHC Richmond Request a Room Form

Stay Information

Number of Guests

Patient Information

Primary Guest Information

Additional Guest Information

Guest #1

Guest #2

Guest #3

Verification

What We Do

Ronald

McDonald

House

Ronald

McDonald

Family Rooms

RMHC

Richmond

Events

RMHC

Volunteer

Program

RMHC Richmond Request a Room Form

Stay Information

Number of Guests

Patient Information

Primary Guest Information

Additional Guest Information

Guest #1

Guest #2

Guest #3

Verification

What We Do

Ronald McDonald House

Ronald McDonaldFamily Rooms

RMHC Richmond Events

RMHC Volunteer Program

Ronald

McDonald

House

Ronald

McDonald

Family Rooms

RMHC

Richmond

Events

RMHC

Volunteer

Program