Housing Application

Housing Waiting List Application

You must complete information for all asterisked (*) items.

Waiting List applications may be submitted two weeks before your arrival
If your visit is less than 2 days away, please call the Housing Office at (206) 838-0610 to be placed on our waiting list.
Applications for the Waiting List must be made by the parent, the legal guardian, or the patient, if the patient is aged 18 to 21.
If your child has Medicaid, you must contact your Medical Transportation Broker to request housing authorization.
Submitting the waiting list application will add your family to our system. THIS IS NOT A RESERVATION. A housing coordinator will call to confirm that we have received your paperwork. At that time, we will ask health and safety screening questions.

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA) PERMISSION

Ronald McDonald House needs access to your child's health information at Seattle Children's Hospital in order to make housing arrangements. If your child has Medicaid / Medical coupons, we must provide Medicaid with your child's health information to see if Medicaid will pay for your housing. This permission must be given by the patient's parent or legal guardian. If the patient is 18 to 21 years, this permission must be given by the patient.

Name of person giving this permission: *

Email Address: *

Relation to patient (must be parent, legal guardian or self, if patient is 18 - 21 years): *

Patient’s age if patient is giving permission:

PATIENT INFORMATION

Full Name: *

Birth Date: *

Sex: *

Male

Female

Race: *

Physical Address: *

City: *

County: *

State: *

Country:

Zip Code: *

Home Phone Number: *

Mailing Address (If different than physical address):

Please include address, city, state, zip code, and county.

VISIT INFORMATION

Reason for visit: *

Expected Date of Arrival: *

Expected stay must be 4 nights or more to qualify

Expected Check Out Date: *

Family Members Planning to Stay: *

Please list the Names, Relationships to Patient, Ages and Phone Numbers of the family members planning to stay. Only immediate family members or those that are part of the patient’s medical care plan are allowed to stay. Unrelated minor residents must be accompanied by their own parent or legal guardian. Patients must be accompanied by their legal guardian or parent. Patients aged 18-21 must be accompanied by an adult caregiver.

PAYMENT INFORMATION

House fees are $25/night, but no family is turned away for an inability to pay. Payments are accepted by families, friends and extended family and Medicaid.

Payment: *

The patient has Medicaid.

We plan to pay for our room fee.

We are unable to pay and the patient does not have Medicaid.

Please enter the amount you are able to pay per night: * $

Does anyone planning to stay need assistance with stairs or need wheelchair accessibility?:

NOTES:

Additional information you would like us to have.

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