Online Guest Stay Request

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1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

Request completed by

Staff

* Social Worker

2. Patient Information

3. Guest Information

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Relationship to Patient

* Email

* Mobile Phone

By providing your mobile number you agree to get occasional text messages from our organization. If you do not want to receive text messages check here:

Do not text my mobile number

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

*County

Check this box to enter your vehicle information

* Vehicle License

* Vehicle Model

* Vehicle Make

* Vehicle Color

* Have you been vaccinated

yes

no

* Have you been in close physical contact in the last 14 days with anyone who is known to have confirmed COVID-19, or Anyone who has any symptoms consistent with COVID-19?

yes

no

Add Another Guest

4. Additional Information

If you have any questions, please contact:

Vicky Sheeler at 402.346.9377 or vsheeler@rmhcomaha.org

Mackenzie Leahy 402.346.9377 or mleahy@rmhcomaha.org

Tina Moulton 402.346.9377 or tmoulton@rmhcomaha.org

Notes regarding this request:

Acceptance

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

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Ronald McDonald House
Charities in Omaha

620 South 38th Ave.
Omaha, NE 68105
402.346.9377
info@rmhcomaha.org

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