Be Our Guest

Be Our Guest
Ronald McDonald House Charities of Northwest Florida

Guest Application

It is our pleasure to provide you with a home away from home while you are staying in Pensacola. Here’s what you can expect during your stay at the Ronald McDonald House:

One private bedroom per family (room sizes vary, sleeping as many as 6 people, a limited number of roll-aways and pack-n-plays are available)

- Private bath and shower facilities
- Kitchen, laundry, and recreation facilities
- TV lounge, reading room, outdoor porch and grill
- Pantry items, fresh foods and prepared meals provided by the community
- Friendly and supportive environment with other families experiencing similar stresses and concerns

- Computer and Internet access

Ronald McDonald House guests must be referred by a medical facility, social worker or designated nurse clinician and have a child 21 years of age or younger receiving medical treatment.

PAST GUESTS: If you have stayed with us within the last 2 years, please contact the House directly. You do not have to complete this form.

Completing this application does not guarantee you and your family a room at RMH. Once the application has been processed, an RMH staff member will contact you to discuss room availability.

If you have any questions during this process, please call us:

RMH Northwest Florida: 850.477.2273

Guest Eligibility/Room Availability
Please check the following to determine if your family is eligible to stay at RMHC-NFWL: *

A referral has been submitted to RMHC-NWFL by the referring medical facility. To check on your referral status, please contact us at 850.477.2273. The patient receiving evaluation and/or treatment is 21 years of age or younger. Guests who will stay at RMHC-NWFL are free of symptoms related to contagious illnesses. To ensure the safety and security of guests, staff and volunteers, you authorize for a background check on all guests 18 and over.
Please call us 24 hours before your requested check-in date to reserve a room based on availability . We cannot guarantee rooms prior to 24 hours because room status changes on a daily basis. *

I understand that RMHC-NWFL cannot gurantee my family a room.
*If you cannot mark all four of the above statements, please contact the Ronald McDonald House Family Services Manager at 850.477.2273.

Patient Information

(Who is going to be the patient recieving medical treatment including high-risk pregnancies in Pensacola, FL? )
Date of Requested Check in *

Month Day Year
Full Name *

First Name Last Name
Gender *

Male Female
Birth Date *

Month Day Year
Unborn?

Yes
Ethnicity
Treatment and Diagnosis Information
Hospital *
If Hospital 'Other'
Dept/Unit *
If Dept/Unit 'Other'
Diagnosis* (e.g. Premature, Lymphoma, Eplilepsy, etc.) *
Birth Weight* ( If child is newborn/premature)
Status *

Inpatient Outpatient

Primary Guest Information

(Who is going to be the main person that we can coordinate with during your stay?)
Full Name *

First Name Middle Initial Last Name
Birth Date *

Month Day Year
Marital Status *

Single Married Divorced
Current Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
E-mail *
Relationship to Patient *

Other Guest

(Who else will need to stay with you? Most rooms accomodate 2–3 adults comfortably. Depending on the room, we can accomodate 2–6 total guests.)

You do not need to enter the primary contact or the patient in this section.
Register Additional Guest One

Yes
Relationship to Patient
Full Name

First Name Middle Intial Last Name
Birth Date

Month Day Year
Address (If different from primary guest)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
E-mail
Register Additional Guest Two

Yes
Relationship to Patient
Full Name

First Name Middle Intial Last Name
Birth Date

Month Day Year
Address (If different from primary guest)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
E-mail (if over 18 years old)
Register Additional Guest Three

Yes
Relationship to Patient
Full Name

First Name Middle Intial Last Name
Birth Date

Month Day Year
Address (If different from primary guest)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
E-mail (if over 18 years old)
Register Additional Guest Four

Yes
Relationship to Patient
Full Name

First Name Middle Intial Last Name
Birth Date

Month Day Year
Address (If different from primary guest)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
E-mail (if over 18 years old)

Emergency Contacts

(Who should we get in touch with in the case of an emergency while you are staying with us?)
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to Patient *

Other Information
Are any aplicants in the Military? *

Yes No
If yes, please list branch and base station.
Primary Guest Place of Employment *
If you are unemployed, you can enter “ Homemaker” as employer or “Unemployed”
Secondary Guest Place of Employment
If you are unemployed, you can enter “ Homemaker” as employer or “Unemployed”
Will you have a vehicle on premises? *

Yes No
Make/Model
Color
Registration State
During your stay
Does anyone staying in your room take medication that requires refrigeration?

Yes No
Will you need a pack ’n play?

Yes No
Other Special Request

House Rules
1. Here at RMHC-NWFL, we strive to keep a clean sanitized and pest free environment. In order to do that we ask that ALL FOOD AND BEVERAGES remain within the kitchen and dining room areas. No food or beverages with the exception of water and ice are allowed in the guest rooms.

2. HELP KEEP THE KITCHEN CLEAN. Families are responsible for cleaning up after themselves and their family in the public and private areas of the House. Guests should rinse their dishes and place them into the dishwashers.

3. SUPERVISON OF CHILDREN under the age of 18 by an adult is required. Children cannot be left alone in guest rooms or left with another guest outside of your party.

4. SAFTEY AND SECURITY. Each room will recieve a key fob at inital check-in that will give access to our front doors. The Ronald McDonald House doors are locked after 7pm during the week day and locked all day on weekends for your own safety. We ask that guests not prop any of our doors.

5. VISITING HOURS are 8:30am- 10:00pm. All visitors should sign in at the front desk when coming and going. Any visitors on House premise after visiting hours will be politely asked to leave.

6. QUIET HOURS are 10:00pm-6am. During these hours, we expect Guests to lower the volume of room televisions and keep conversations at a normal volume level.

7. SMOKING is NOT allowed in any areas inside this Ronald McDondald House. Please use the designated area only.

8. We are a SHARED HOME. We ask that all Guests wear approiate attire in all common areas.

9. Possesion or use of ALOCHOLIC BEVERAGES, ILLEGAL DRUGS, or FIREARMS in or on RMH property is strictly prohibited. Also, foul language, or inappropiate behavior is not acceptable.
Guest Rooms
1. We do ask for a $10 a night donation. Families are requested to contribute what is comfortable, and no family is turned away if they are not able to pay.

2. We ask our families to use our House nightly by at least one family member.
Check Out
1. All families are required to sign up on the check-out board prior to check out, located in the pantry area.

2. Upon check-out, we ask our guests to please clean their bathroom, sweep the floors and take all linens off the beds and leave in their laundry basket.

3. A staff member/volunteer will check that all personal belongings were collected. Room Keys and RMH Badges should be returned at check out.
Name of Primary Guest agreeing to all of the above and acting as responsible party for all individuals in the family who are applying for temporary lodging at RMH Northwest Florida.
Electronic Signature *
Date of Agreement

Month Day Year
Should be Empty:

Be Our Guest

House Rules

Guest Rooms

Check Out