Request a Room

 
On-Line Room Request Form

1 Request made by:   
2 Has your family stayed at Ronald McDonald House Hershey before?:
3 If "yes" to number 2.; when were you last here?: 
4 Patient's name and age:  
5 Is patient currently admitted at Hershey Medical Center?: 
6 If "yes" to number 5, what department?:
7 Brief diagnosis/procedure:
8

For outpatients and patients not yet admitted:  

Admitting/appointment time and date:

Complete mailing address, phone number
and e-mail address (if applicable):    

9 Room request arrival date: 
10 Number of nights?:
11

Guest names, age, and relation to patient*
12 Crib needed?:      
13 First floor or stair lift needed?: 

 

PLEASE NOTE:  YOU MAY RECEIVE THE MESSAGE "FRONT PAGE ERROR" AFTER YOU HIT THE SUBMIT BUTTON.  YOUR REQUEST WILL STILL BE RECEIVED.