Pasadena Ronald McDonald House

Completing and sending this form does not guarantee a room reservation. All information submitted will be confirmed with the Hospital and Social Workers referenced in this Room Request.


	General Information

*Date of Request:

/ /

Returning Family?:

Yes
No

*Patient's First Name:

*Patient's Last Name:

*Patient's Date of
Birth:

/ /

*Patient's Age:

*Sex?:

Male
Female

*Accompanying
Parent(s) or
Guardian:

*Home Address:

*City:

*State:

Zip:

*Country:

*Home Phone:

- -

Cell:

- -

Email:


	Medical Information

*Diagnosis:

Comments / Specifics:

(chars left: 1000)

*Child Is Currently:

*Hospital:

Referred By:

Referrer Title:

Referrer Phone:

- - x

Wheelchair Needs:

Yes
No


	Method of Payment

*Payment Type:

If you chose Sponsored, please complete the Comments area below.

Comments:

(chars left: 1000)


	Request Details

*Arrival Date:

/ /

*Estimated Departure:

/ /

Please enter the total number of individuals who will be staying at the House.

*Adults:

*Children (0 for
none):


	Important Information for Families

Check In Hours: 9:00am - 9:00pm (Check Out is 12:00pm)

Room request does not guarantee a reservation. Call for confirmation. 626-585-1588 x 0

A $15 donation per night is requested plus a $10 cash key deposit for each room key needed required


	For Office Use Only

Date & Time:

Proposed Room select
multiple if needed:

EC:

Request Is:

Cancellation Reason:

Staff Comments:

Hse ML:

False

ASI:

False

Staffer Initials:

Pasadena Ronald McDonald House

Room Request Form