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HOW TO STAY

HOW TO STAY

RMHC Richmond Request a Room Form

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The Request a Room form must be completed and submitted by a medical
professional at the hospital serving the patient.

If you have any questions, please call 804.355.6517.

Stay Information

Today's Date *
Date of Arrival *
Length of Stay *Indicate days, weeks, or months

Number of Guests

Adult Guests *
Children Guests *

Patient Information

Patient Name *
DOB (Must be 21 or younger) *
Gender *
MaleFemale

Hospital Medical Info

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
Phone Number
Relationship to Patient

Additional Guest Information

Guest #1

Name
Age
Relationship to Patient

Guest #2

Name
Age
Relationship to Patient

Guest #3

Name
Age
Relationship to Patient

Accommodations

Does the family have their own form of transportation? *
Do any guests have physical limitations that would prevent them from climbing stairs? *

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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

Hospital Medical Info

Primary Guest Information

Additional Guest Information

Guest #1

Guest #2

Guest #3

Accommodations

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

Hospital Medical Info

Primary Guest Information

Additional Guest Information

Guest #1

Guest #2

Guest #3

Accommodations

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