Guest Registration : Ronald McDonald House Charities

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Guest Registration

"*" indicates required fields

Have you stayed at RMHC of Marshfield in the past?*

Yes

No

In which year was your most recent stay at RMHC of Marshfield.*

Parent or Guardian Information

Parent/Guardian 1*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Relationship to Patient*

Contact Phone Number*

Email

Previous/Maiden Names

Previous State(s) of Residency

Active Military or Veteran?*

Yes

No

Do you wish to add a second Parent/Guardian?*

Yes

No

Parent/Guardian 2*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Relationship to Patient*

Contact Phone Number

Email

Previous/Maiden Names

Previous State(s) of Residency

Active Military or Veteran?*

Yes

No

Are any additional family members or supporters planning to stay overnight?*

Yes

No

Name*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Relationship to Registrant*

Name

First Middle Last

Date of Birth

MM slash DD slash YYYY

Relationship to Registrant

Name

First Middle Last

Date of Birth

MM slash DD slash YYYY

Relationship to Registrant

Patient Information

First Name*

Last Name*

Date of Birth

MM slash DD slash YYYY

Sex*

Male

Female

Ethnicity*

Facility*

Home/Mailing Address*

Street Address Address Line 2 City State ZIP Code

County*

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone*

Relationship to Registrant

About Your Stay

Anticipated Arrival Date*

MM slash DD slash YYYY

Estimated Length of Stay

Vehicle Make/Model/Color

I would like to utilize these additional services during my stay: (Select all that apply)

Medela Symphony Hospital Grade Breast Pump

Pet Therapy

Spiritual Support

Child Life Therapy (Sibling Support)

Support with Clothing/Necessities

Translator/Language Support

Transport Assistance

YMCA Pass

Vandehey Water Aquatic Center Pass (Seasonal: Summer)

Music Support

Δ

Ronald McDonald House
Charities Marshfield
803 West North Street
Marshfield, WI 54449
715-387-5899 ( voice )
715-389-5991 ( fax )
Staff@RMHCofMarshfield.org

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Terms and Conditions • Privacy Policy • Non-Discrimination Policy • ©2024 RMHC Marshfield • site by Chip Thompson

The following trademarks used herein are owned by McDonald’s Corporation and its affiliates; McDonald’s, Ronald McDonald House Charities, Ronald McDonald House Charities Logo, RMHC, Ronald McDonald House, Ronald McDonald Family Room, and Ronald McDonald Care Mobile.

RMHC is recognized as a public charity under Internal Revenue Code section 509(a) and has 501(c)(3) status. Donations to RMHC are deductible. Donors should consult their tax advisor for questions regarding deductibility. The RMHC EIN is 93-0833012. A copy of the RMHC determination letter is available upon request.