Ronald McDonald House Pittsburgh Online Registration

Requesting Individual Information*
First Name Last Name
Email
Phone*
Phone #2
Address Registration
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Information
Number of Patients*
Patient Name*
First Name Last Name
Patient Date of Birth*
MM slash DD slash YYYY
Patient Diagnosis / Hospital Department Being Utilized*
Medical Facility*
Expected Arrival Date*
MM slash DD slash YYYY
Approximate Length of Stay*
MM slash DD slash YYYY
Patient 2 Name*
First Name Last Name
Patient 2 Date of Birth*
MM slash DD slash YYYY
Patient 2 Diagnosis / Hospital Department Being Utilized*
Patient 2 Medical Facility*
Patient 2 Expected Arrival Date*
MM slash DD slash YYYY
Patient 2 Approximate Length of Stay*
MM slash DD slash YYYY
Patient 3 Name*
First Name Last Name
Patient 3 Date of Birth*
MM slash DD slash YYYY
Patient 3 Diagnosis / Hospital Department Being Utilized*
Patient 3 Medical Facility*
Patient 3 Expected Arrival Date*
MM slash DD slash YYYY
Patient 3 Approximate Length of Stay*
MM slash DD slash YYYY
Additional Registered Guests
Additional Registered Guests*
List any additional family members and guests and their relationship to child; over 18 must have I.D.

Note: you'll need to fill out a Background Check for all registered guests
Additional Family Member #1 Name
Family Member #1 Relation to Patient
Is Family Member #1 Under 18 Years Old?
- Yes, under 18
Additional Family Member #2 Name
Family Member #2 Relation to Patient
Is Family Member #2 Under 18 Years Old?
- Yes, under 18
Additional Family Member #3 Name
Family Member #3 Relation to Patient
Is Family Member #3 Under 18 Years Old?
- Yes, under 18
Any Restricted Guests?*
If none, enter 'none'.
Any Handicap Needs?*
If none, enter 'none'.
Has anyone been exposed to any contagious disease in the last month, including chicken pox, measles, or mumps?*
- Yes
- No
NOTE!

Prior to arrival, all parents/guardians must have an approved criminal background check.

You're about to complete step 1 by submitting the room request application. After you submit this form you will see a link to step 2. All guests must complete a criminal background check to determine eligibility.
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State*
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CORPORATE OFFICE

RONALD MCDONALD HOUSE CHARITIES OF PITTSBURGH AND MORGANTOWN INC.

The Plaza Building
451 44^th Street – Penthouse Floor
Pittsburgh, PA 15201

Phone: 412-362-3400
Fax: 412-362-8540

RONALD MCDONALD HOUSE PITTSBURGH

The Plaza Building
451 44^th Street – Penthouse Floor
Pittsburgh, PA 15201

Phone: 412-362-3400
Fax: 412-362-8540

RONALD MCDONALD HOUSE MORGANTOWN

841 Country Club Dr.
Morgantown, WV 26505

Phone: 304-598-0050
Fax: 304-599-0780

RONALD MCDONALD HOUSE PITTSBURGH & MORGANTOWN

© RMHC

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. A copy of the RMHC determination letter is available upon request.

Ronald McDonald House Pittsburgh Online Registration

Patient Information

Additional Registered Guests

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