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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 (617) 398-6458.

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

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) at Boston Harbor. 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 note that guest rooms can accommodate a maximum of 5 people (if room occupants are co-sleeping). We understand the importance of having family with us; however, for safety and service reasons, we can not exceed the occupancy limit of the guest rooms. If more than 5 people are requesting to stay as guests, please include the Name, Date of Birth, & Relationship to the Patient for additional guests in the space provided at the end of this form.

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

Please contact a Family Services Coordinator if you have additional needs or questions at 617-398-6458.