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| If you are a part time student, please list the nights of stay that you will need in the Comments Section. |
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| Please add any additional dietary restrictions/special diet needs and/or allergies here |
| Please provide the name of an individual that you pre-authorize Pacifica to contact in case of an emergency, medical, missing person, or otherwise. |
| Email address of your emergency contact |
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| Phone number of your emergency contact |
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| Information is requested for your protection and convenience but is not mandatory |
| Information is requested for your protection and convenience but is not mandatory |
| Information is requested for your protection and convenience but is not mandatory |
| Information is requested for your protection and convenience but is not mandatory |
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| 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. |
| 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 |
| I agree to the above waiver |