Room Request

Language / Langue

Our Ronald McDonald House
When sick children need their families close by, our House is their home.

Request Information

Please ensure all mandatory fields are completed with as much information as possible. For Healthcare professionals, if you are unsure if a family has stayed with RMHC Atlantic before please indicate No for returning family. Mandatory fields are indicated in Red.

Who is filling out this form? *

Family member

Hospital staff / Social worker

Returning family? *
No Yes

Date of first appointment

Date room required

Estimated departure date

Patient to stay first night

Medical Information

To help us identify how best to meet the patient/family needs, please complete the medical information below.

Diagnosis

If other diagnosis, please specify

Reason for hospital visit

If other reason, please specify

Hospital / Medical facility

Caregiver / Guardian Information

All caregivers must be, at minimum, 18 years of age

Primary caregiver/guardian first name

Primary caregiver/guardian last name

Gender

Relationship to patient

Pronoun

If Something Else, Please Specify

Birth date

Will stay at the house

Uses wheelchair / walker

Uses oxygen

Requires assistance in emergency

Secondary caregiver/guardian first name

Secondary caregiver/guardian last name

Gender

Relationship to patient

Pronoun

If Something Else, Please Specify

Birth date

Will stay at the house

Uses wheelchair / walker

Uses oxygen

Requires assistance in emergency

Primary Address

Address

City

Province / State

Postal code / Zip

Country

Primary Contact Information

Phone number(s)

Email address

Alternate email address

Primary language spoken

If other language, please specify

Special Requests

RMHC Atlantic will make every effort possible to accommodate all requests when possible.

Accessible Room
Cot
Playpen

Vehicle Information

If you are unsure of the requirement for parking please indicate No.

Vehicle to be parked at RMH? *
No Yes

Additional Notes

Please provide any additional details that allow RMHC Atlantic to best support you during your stay.
If you are a first time family to RMHC Atlantic please list your social workers name and telephone number below.

By clicking the SUBMIT button below you are confirming that all information entered is accurate.

Ronald McDonald House Charities® Atlantic