Request Accommodation | Ronald McDonald House - South Island, New Zealand

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Request for Accommodation

Download the Accommodation Request form (PDF) or fill in the online form below.

* Email Address:

* Applicant Name:

* Date:

We would like to request accommodation for:

1. Last Name / First Name:

Relationship to Patient:

Date of Birth (if child):

Male Female

2. Last Name / First Name:

Relationship to Patient:

Date of Birth (if child):

Male Female

3. Last Name / First Name:

Relationship to Patient:

Male Female

4. Last Name / First Name:

Relationship to Patient:

Male Female

Address:

Postcode:

Phone Number (Home):

Cell Phone:

First visit Return visit

Date of Arrival:

Expected Date of Discharge:

Expected Time of Arrival:

Before 5pm After 5pm

Clients Details (child receiving care)

Surname:

First Names:

Address:
(if different from
parent/guardian)

Date of Birth:

Gestation (if unborn baby):

EDD (Expected Date of Delivery):

Christchurch Hospital
Christchurch Woman's
Burwood
Other (Please specify)

Hospital:

Other Hospital (if applicable):

Ward (if known):

Diagnosis:

NHI Number (if known):

Yes No Unsure

Is the client eligible for
Accommodation under the
2006 National Travel
Assistance Scheme?

If No, please give brief reason:

Yes No

Has the client been registered with
Healthpac for Travel
and Accommodation?

If No, please state reason:

If Yes, please complete the following:

Client Number (if processed):

Date applied for
(if not processed):

Please enter your security code:

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