GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.

Referrals are to be submitted by social workers and hospital personnel only.

IMPORTANT:

Please include each individual's email address. This email address will send the online criminal background check form. The individual will receive an email from no-reply@selection.com with the form to complete and return.

Submittal of a request does not guarantee or hold a room. Guests must pass a background check, provide a government-issued photo ID, complete the registration/orientation process, and agree to/ sign RMHC Central GA Conditions of Stay.

If you have any questions regarding a family's eligibility, please contact RMHC Program staff at 478-746-4090.

1. Stay Request

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

* Distance from RMHC

Social Worker Email (enter if blank/different)

2. Patient Information

If there is more than patient, please click + Add Another Patient to submit information for each person.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Ethnicity

* Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

* Patient's Room Number

* Background Check Consent?

* Are Mother & Father Married?

* Is family Insured?

* Does Family Receive WIC/TANF?

Add Another Patient

3. Guest Information

Guests who are 18 years of age or older and staying overnight, must complete a background check before a room is confirmed.

If there is more than one guest staying, please click + Add Another Guest to submit information for each person.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

*Relationship to Patient

Contact Information

* Email

* Mobile Phone

By providing your mobile number, please accept to get text messages from our organization. Message and data rates may apply. Visit our website for terms and privacy information. To stop texting, do not accept.

I accept to receive text messages on this number

* Country

* Street 1

Street 2

* City

* State/Province

* Zip/Postal Code

* County

Add Another Guest

4. Additional Information

IMPORTANT:

1. Only social workers/medical staff may submit this referral. An RMHC staff member may call the submitting social worker/medical staff to verify the referral. Please list your name and direct phone number.

2. A government-issued photo ID must be presented at the time of check-in.

3. Only guests listed on the referral will be allowed to stay at RMHC.

4. RMHC does not have staff covering the front office after business hours. Any referrals received after office hours will be processed the following day.

* After processing the referral, a staff member will contact the family to confirm their room. At that time, the staff member will schedule a check-in time for the families to arrive.

* Referring Persons Role

* Referring Persons Name

* Referring Persons Phone

* Referring Persons Email

Notes regarding this request:

Acceptance

Your request will be processed. Do you want to continue?

Submit Another Request

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Phone: 478.746.4090

Ronald McDonald House Charities
of Central Georgia
1160 Forsyth Street
Macon, GA 31201

Privacy | Terms | Refunds | Mobile

GUEST REQUEST TO STAY ONLINE FORM

Guests who are 18 years of age or older and staying overnight, must complete a background check before a room is confirmed.

If there is more than one guest staying, please click + Add Another Guest to submit information for each person.

IMPORTANT:

1. Only social workers/medical staff may submit this referral. An RMHC staff member may call the submitting social worker/medical staff to verify the referral. Please list your name and direct phone number.

2. A government-issued photo ID must be presented at the time of check-in.

3. Only guests listed on the referral will be allowed to stay at RMHC.

4. RMHC does not have staff covering the front office after business hours. Any referrals received after office hours will be processed the following day.

* After processing the referral, a staff member will contact the family to confirm their room. At that time, the staff member will schedule a check-in time for the families to arrive.

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