Ronald McDonald House Charities Referral Form

Fields Marked with ** are required.

Date:	A value is required.Invalid format.
Time:
Arrival Date:	A value is required.**
Patient's Name:	A value is required.**
Age:	A value is required.**
Diagnosis:	A value is required.**

Medical Facility & Unit:	A value is required.**
Referred By:	A value is required. ** Only a nurse, social worker or doctor can make a referral
Referred By Phone:	A value is required. **
Number of Guests:
Name(s):	A value is required.**
Previous RMHC Resident:	Yes No If yes: Patient's Name: When?
Where does guest live?	A value is required.** Families must live 30 miles from Reno and have a child receiving medical care in the Reno area to stay at the Reno Ronald McDonald House.
How or where can we reach guest?

Does any guest have a contagious disease?	Yes No
Does guest smoke?	Yes No
Does guest know to call the morning of checking in to see if a room is available?	Yes No
Does guest know to check in between 2:30-7:30 p.m.?	Yes No
Does this family qualify for the Adopt-A-Night Program?	Yes No
Special Problems/Comments:

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WE ARE LOCATED AT: 323 Maine Street, Reno Nevada 89502
775-322-4663 Fax 775-322-8670
E-MAIL: info@rmhc-reno.org . CLICK HERE FOR DRIVING DIRECTIONS

© 2011 McDonald's
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

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