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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Email type Email type

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Address

Home Work

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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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

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Patient Date of Birth

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Unit of Hospital

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Parent/Guardian Full Name (#1)

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Parent/Guardian Full Name (#2)

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Home Address (Street)

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

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Home Address (City, State and Zip Code)

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Contact Phone No.

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Contact E-mail

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Relationship to the Patient

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Do you rely on public transportation?

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Will you have other children staying with you?

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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?

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

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Estimated Departure date.

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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.

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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.

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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

All transactions are secure and encrypted

Credit card Bank payment

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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Account holder name Account holder name

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Email address Email address

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Bank name

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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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