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Boston Online Guest Stay Request
Providence Online Guest Stay Request

Please select your preferred stay location (Boston or Providence) from the tabs at the top *Guest Stay Request for Social Workers/Referrers**

(999) 999-9999?999

HOSPITAL STAFF/SOCIAL WORKERS ONLY

Please complete this form, being sure to include information for all persons requesting to stay.

All those over 18 years of age must have completed answers for the Yes/No questions in section 3.

All fields marked with an asterisk (*) are required fields.

If you have questions about this form, please contact us at (401) 274-4447.

Note: Please use only Google Chrome or Mozilla Firefox as your browser; Internet Explorer is no longer supported.

1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Ethnicity

* Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

* Patient's Age

* Name of Doctor or Medical Professional

* Referring Persons Role

* Referring Person Name

* Referring Person Phone

* Referring Person Email

Add Another Patient

3. Guest Information

Our goal is to provide a safe & secure environment for all guests. The following questions are required of all adults requesting a stay at the Ronald McDonald House (RMH) Providence. Certain situations may require more information. The referring medical professional must provide additional details (at the end of this section) for any 'Yes' or 'Unknown at This Time' answers.

Please add a contact phone number for atleast 1 parent or guardian staying at the house This field is optional but we need atleast 1 phone number to reach you, when needed.

Please contact us if you have additional needs or questions at (401) 274-4447.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Relationship to Patient

* Email

Type of Email

Home Phone

* Mobile Phone

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

* Name of Emergency Contact for Parent

* Is the address provided the families permanent address?

Yes

* Phone of Emergency Contact for Parent

* Has This Family Stayed Here Before?

Yes

* Any Special Requests/Needs? Disability accessible room? Please detail below

Add Another Guest

4. Additional Information

* Is the family aware that our check in time is between 9am and 8pm?

Yes

* Please make family aware that we ask for a $10 fee per night to help cover the cost of their stay. Are they able to contribute at this time?

Yes

* Are both parents over 18 yrs?

Yes

* Does family need housing from 3 to 90 days? If No, please call us for consideration of a different stay length.

Yes

Any safety or social concerns? Drug abuse,child abuse, DCF/DCYF involvement, domestic violence, felonies, etc? If so, Please call RMHC to discuss.

Yes

* Are you aware of any Infectious/Contagious Diseases in the family? If so, contact us.

Yes

* Is Patient Staying in RMHC housing?

Yes

* Is patient 21 or younger? Or High-risk pregnancy?

Yes

* Is an Interpreter Needed? Note that interpreters are required for checkins and checkouts and 24/7, and provided by the hospital

Yes

Notes regarding this request:

Upon submission of this form you should receive email confirmation that this form was received. If you do not receive email confirmation- please let us know.
Normally, we will get back to you within 24 hours or the next business day after receiving the form. If you do not hear from us by then-feel free to give us a call at 401-274-4447.

Acceptance

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

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Ronald McDonald House Charities® of New England

250 1st Avenue Charlestown/Boston, MA 02129

Ph: 617-398-6458

45 Gay Street Providence, RI 02905

Ph: 401-274-4447

Tax ID #22-2760752

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Please select your preferred stay location (Boston or Providence) from the tabs at the top *******Guest Stay Request for Social Workers/Referrers********

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Please select your preferred stay location (Boston or Providence) from the tabs at the top *Guest Stay Request for Social Workers/Referrers**