For Families

Online Room Request Form

To be completed and submitted by social workers only. Please provide all information requested.

*Indicates a required field

Social Worker
Contact Person
Contact Number
Contact E-mail		(leave empty if unavailable)
*First Day of Need
*Patient Name
Patient Age
*Guests' Name:		Guest's DOB
Relationship to Patient
Guest Name		Guest's DOB
Relationship to Patient
Guest Name		Guest's DOB
Relationship to Patient
*Hospital
Department
*Patient Birth Date

*Patient's Street Address
*Patient's City		(minimum of 50 miles)
*Patient's State
*Patient's Zip Code
*Number of People in Room (maximum 4)
No one under 18 may stay at the House without a parent/guardian.
Special Needs		Wheelchair Acess Crib
		Other (specify below)
*Is anyone in the family immunosuppressed? Please type "YES" or "NO":
By submitting this form the requesting social worker accepts responsibility for understanding the Ronald McDonald House Occupancy and Room Request Guidelines and has confirmed that this family meets the requirements for temporary lodging at the RMH. All requests will be placed on the Waiting List in the order received. When a room becomes available, the Guest, Social Worker, or Contact Person listed above will be notified. If a family has been offered a room and they decline, their room referral needs to be resubmitted for them to be put back on the list. Requests are taken no earlier than 3 working days in advance of first day of need, which includes the first day of need. For Monday – Submit on Thursday For Thursday – Submit on Tuesday For Tuesday – Submit on Friday For Friday – Submit on Wednesday For Wednesday – Submit on Monday To check on a room request previously, call (314) 773-1100 or email jbraucksieker@rmhcstl.com.