Guest Stay Request Online Form

Complete your online request and click on SUBMIT.


1. Stay Request



2. Patient Information (not parent)


* Race: Please indicate how you identify the patient (select one or more) ?
* Please indicate if you identify the patient as Hispanic/Latino?
* Does your patient child have health insurance through Florida Medicaid?
* Medicaid Plan Name
If Other please include here
Patient Insurance Member ID#


3. Guest Information (parent/caregiver or siblings)


Contact Information
By checking this box I agree to receive transactional/informational SMS communications from RMH Tampa Bay. Messages frequency may vary. Message and data rates may apply. Reply HELP for help or STOP to opt-out. I also accept Terms of Service and Privacy Policy.

* Race: please indicate how you identify yourself (select one or more)?
* Please indicate if you identify yourself as Hispanic/Latino?
Please indicate your primary language:


4. Additional Information

Do you have any access requirements you would like us to be aware of (use of stairs, etc.) ?
Does anyone staying with us require in-room refrigeration for medical purposes (i.e. medication or breastmilk)?
Do you need Translation Services?
If you need Translation Services, for which language?
Does anyone staying with us require a service animal? (Note: Service Animals are defined by the Americans with Disabilities Act;)
Enter the number of people who stay at the primary residence with the patient?
Does anyone in your household staying at Ronald McDonald House have a cognitive or physical disability?
In the next 3 questions, each individual can identify as more than one category. Enter the number of individuals staying at RMHC who identify as Veterans/Military:
Enter the number of individuals staying at RMHC who identify as Military Spouse:
Enter the number of individuals staying at RMHC who identify as First Responders:

Notes regarding this request:





Acceptance
Your request will be processed. Do you want to continue?

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