Room Request RSVP Page for Giveffect Demo

Contact information

First name First name

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Last name Last name

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Phone Phone

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Phone type Phone type

Email address Email address

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Home Work

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Apartment, suite, etc. (optional) Apartment, suite, etc. (optional)

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ZIP code ZIP code

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Additional details

Room Requests are submitted by families and will be reviewed by the staff at the House. If the staff determines that you/your family is eligible to stay at the House, you will be placed on our wait-list. Generally speaking, the wait-list is triaged by how critical the child's illness is and how far the family lives from the treatment hospital.

Patient Name Patient Name

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Patient Date of Birth Patient Date of Birth

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Unit of Hospital Unit of Hospital

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Parent/Guardian Full Name (#1) Parent/Guardian Full Name (#1)

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Parent/Guardian Full Name (#2) Parent/Guardian Full Name (#2)

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Home Address (Street) Home Address (Street)

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Home Address (Apt. No. or Other Additional Information) Home Address (Apt. No. or Other Additional Information)

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Home Address (City, State and Zip Code) Home Address (City, State and Zip Code)

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Contact Phone No. Contact Phone No.

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Contact E-mail Contact E-mail

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Relationship to the Patient Relationship to the Patient

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Do you rely on public transportation? Do you rely on public transportation?

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Will you have other children staying with you? Will you have other children staying with you?

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In what region do you live? In what region do you live?

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Would you like to use the House for the day or stay in a room overnight? Would you like to use the House for the day or stay in a room overnight?

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If you wish to stay overnight, provide a requested start date If you wish to stay overnight, provide a requested start date

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Estimated Departure date. Estimated Departure date.

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Who referred you to our House? Who referred you to our House?

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If referred by a hospital, provide the name and phone number of social worker/hospital employee who referred you. If referred by a hospital, provide the name and phone number of social worker/hospital employee who referred you.

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Have you or anyone asking to stay with us stayed at a Ronald McDonald House before? Have you or anyone asking to stay with us stayed at a Ronald McDonald House before?

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If anyone asking to stay has stayed at a House before, provide the name of the House and dates of the stay. If anyone asking to stay has stayed at a House before, provide the name of the House and dates of the stay.

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Registration fee

A registration fee is required to participate

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$10

Processing Fee

Fee to process your request

Payment

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Credit card

Card number

Test credit card number 4242424242424242 can be used in Trial Mode. Click here for more test cards

Cardholder name Cardholder name

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Email address Email address

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I happily agree to cover the fees so that 100% of the amount goes to Giveffect Demo

Billing address

Same as donor address

Address Address

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Apartment, suite, etc. (optional) Apartment, suite, etc. (optional)

City City

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Country/region Country/region

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State State

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ZIP code ZIP code

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