REQUEST A ROOM FORM

You can request a room at the Philadelphia Ronald McDonald House online. A staff member at Philadelphia Ronald McDonald House will contact you to complete your request.

If your room request is same day, please call the Family Services Office at 267-969-6220.

For both our Chestnut Street and Front & Erie locations, please call 215.387.8406 between 9 a.m. and 9 p.m. EST.

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PERSONAL INFORMATION OF REQUESTER

Name
Address

PATIENT INFORMATION

Date of Birth
Must be 21 years old or younger to stay.
If your room request is same day, please call the Family Services Office.
Have all patients and family members who will be staying at the House been vaccinated for measles, mumps, and rubella (MMR), and been vaccinated for and/or diagnosed with chickenpox in the past?
Are all individuals requesting to stay at the House vaccinated for COVID-19?
Does the patient have medical insurance? (Including state run insurance, such as Medicaid, or private)

ROOM OCCUPANCY

Please list the names of each room guest and their relationship to the patient. Please note that each room can only accommodate up to 4 individuals.

Guest 1

Guest Date of Birth
Guardian?

Guest 2

Guest Date of Birth
Guardian? (copy) (copy) (copy) (copy)

Guest 3

Guest Date of Birth
Guardian? (copy) (copy) (copy)

Guest 4

Guest Date of Birth
Guardian? (copy) (copy)

SPECIAL NEEDS

Checkboxes