Student First Name *
Student Last Name *
Preferred Name
Email *
Phone Number *
Street Address *
Address 2
City *
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Country * United States Canada United Kingdom Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia (Hrvatska) Cuba Cyprus Czech Republic Democratic Republic Of Congo (Zaire) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guinea French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia And South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis And Futuna Islands Western Sahara Western Samoa Yemen Zambia Zimbabwe
Email newsletter Please add my name and email for upcoming newsletters and future events
Full Time Student or Part Time Student Full Time Part Time If you are a part time student, please list the nights of stay that you will need in the Comments Section.
Dietary Restrictions/Special Diets *
Diet Notes Please add any additional dietary restrictions/special diet needs and/or allergies here
Emergency Contact Full Name * Please provide the name of an individual that you pre-authorize Pacifica to contact in case of an emergency, medical, missing person, or otherwise.
Emergency Contact Email Email address of your emergency contact
Emergency contact relationship
Emergency Contact Phone Number * Phone number of your emergency contact
In The Event Of An Emergency * I understand that in the event of an emergency while on the Pacifica campus, it is the procedure of Pacifica, in its discretion, to call 911 to request emergency services. I on behalf of myself, my heirs, assigns, personal and legal representatives and next of kin HEREBY AGREE TO INDEMNIFY PACIFICA, IT’S TRUSTEES, OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, AFFILIATES, SPONSORING ORGANIZATIONS AND OWNERS, FOR ANY AND ALL COSTS INCURRED IN CONNECTION THEREWITH. I FURTHER UNDERSTAND AND AGREE THAT PACIFICA, IT’S TRUSTEES, OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, AFFILIATES, SPONSORING ORGANIZATIONS AND OWNERS, SHALL HAVE NO RESPONSIBILITY FOR EMERGENCY MEDICAL OR OTHER TREATMENT. I HEREBY RELEASE PACIFICA, IT’S TRUSTEES, OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, AFFILIATES, SPONSORING ORGANIZATIONS AND OWNERS, FROM ALL LIABILITY IN CONNECTION WITH ITS ACTIONS OR NON-ACTION TO OBTAIN SUCH TREATMENT AND FOR THE ACTIONS OR NON-ACTION OF ANY PERSON OR PERSONS PROVIDING SUCH EMERGENCY ASSISTANCE OR TREATMENT. I HEREBY ACKNOWLEDGE AND UNDERSTAND THAT PACIFICA DOES NOT MAINTAIN: ANY MEDICALLY OR EMERGENCY TRAINED PERSONNEL ON CAMPUS; OR MEDICAL INSURANCE FOR ITS STUDENTS, INVITEES, GUESTS OR VISITORS, AND THAT OBTAINING AND PAYMENT FOR MEDICAL CARE WHILE A STUDENT, INVITEES, GUEST OR VISITORS AT PACIFICA IS MY RESPONSIBILITY. IN THE EVENT THAT I WISH EMERGENCY MEDICAL TREATMENT OR TRANSPORTATION THROUGH SOME MEANS OTHER THAN THAT PROVIDED BY 911, I WILL BEAR SOLE RESPONSIBILITY FOR MAKING SUCH ARRANGEMENTS AND PAYMENT FOR SUCH SERVICES AND TRANSPORTATION.
Emergency Consent *
Medical Issues Information is requested for your protection and convenience but is not mandatory
Special Health Related Needs or Conditions Information is requested for your protection and convenience but is not mandatory
Current Medications Information is requested for your protection and convenience but is not mandatory
Allergies Information is requested for your protection and convenience but is not mandatory
Changes to Housing Status * I agree to notify the Guest Services Office in writing of any changes to my housing status at least 1 week prior to the next session start date. All changes must be sent to the Guest Services Department, at GuestServices@pacifica.edu. I agree to be responsible for any charges incurred due to my failure to notify the Guest Services Office.
Housing Policy * All enrolled students must have a current Residential Accommodations form on file with the Guest Services Office. All changes must be made in writing. In order to avoid charges REQUESTS FOR CHANGES IN DATES OF STAY MUST BE RECEIVED AT LEAST 1 WEEK PRIOR TO SESSION START AND ARE SUBJECT TO AVAILABILITY. NOTICE OF ABSENCES MUST BE RECEIVED AT LEAST 5 DAYS PRIOR TO SESSION START. If planning to move to Santa Barbara or Ventura County, students are required to notify the Guest Services department immediately. A change to a “Non-Residential Status” resulting from a move to Santa Barbara or Ventura is made on receipt of proper documentation and approval by the housing committee.
Please email your proof of Residency
Damages to Pacifica Property * Student/Guest agrees to be liable for damages or other losses that Student/Guest causes, while on campus, to assigned room or any of Pacifica Graduate Institute's furniture or equipment, or any other Institute property, except for ordinary wear and tear. If damage is done in excess to normal wear and tear, Student/Guest may be responsible for associated fees.
Custom question for date help text Non-session nights are available to you by choosing extra nights below. An additional fee will be charged for each extra night selected. Please note, the night your session ends is considered a Non-Session night and not included in your residential fees. Please see below for more information regarding accommodations and additional nightly fees. If you are a Non-Residential student, please scroll down and select “Local Resident” and continue with the registration process.
Digital Signature * By typing your name in the above box you are agreeing to the terms and conditions listed in this form
Please include your full name and today's date: Full Name 00/00/0000
Waiver of Liability * THE USE OF FACILITIES AT PACIFICA MAY INVOLVE THE RISK OF SERIOUS INJURY TO ME, WHETHER I OR SOMEONE/SOMETHING ELSE CAUSES IT. AS SUCH, I ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS, PERSONAL AND LEGAL REPRESENTATIVES AND NEXT OF KIN, UNDERSTAND AND VOLUNTARILY ACCEPT AND ASSUME THE FULL RISK OF ANY AND ALL INJURIES, DAMAGES OR LOSS, REGARDLESS OF THE SEVERITY, THAT I MAY SUSTAIN AS A RESULT OF BEING ON THE PACIFICA CAMPUS. I FURTHER AGREE ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS, PERSONAL AND LEGAL REPRESENTATIVES AND NEXT OF KIN, TO WAIVE AND RELINQUISH, FULLY RELEASE AND FOREVER DISCHARGE PACIFICA, ITS TRUSTEES, OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, AFFILIATES, SPONSORING ORGANIZATIONS AND OWNERS, FROM ANY AND ALL CLAIMS FOR INJURIES, DAMAGES OR LOSS THAT I MAY INCUR WHILE ON THE PACIFICA CAMPUS, AT PACIFICA EVENTS AND FACILITIES OWNED, RENTED AND/OR INCLUDING, WITHOUT LIMITATION, PERSONAL, BODILY OR MENTAL INJURY, ECONOMIC LOSS, OR ANY DAMAGE TO ME RESULTING FROM ACTIONS THAT MAY BE FOUND TO BE NEGLIGENT. I HAVE READ AND FULLY UNDERSTAND THE ABOVE IMPORTANT INFORMATION, ASSUMPTION OF RISK AND WAIVER OF CLAIMS. I UNDERSTAND THAT THIS WAIVER OF LIABILITY WOULD NOT APPLY TO ME IF I DO NOT VISIT, ACCESS, OR USE PACIFICA FACILITIES, OR DO NOT ATTEND PACIFICA SPONSORED EVENTS. I agree to the above waiver