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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. |
| For Double/Shared occupancy at Best Western-As we wish to create the most comfortable, safe, and accommodating environment during your on campus residential sessions, providing the above information will assist in pairing you with a roommate, if you have selected "Double Occupancy/Shared Room". We appreciate any information that you wish to provide.
Any specific needs, comments, or requests can be noted in the comments section and all will be taken into consideration for roommate assignment. Requests for a specific roommate are accommodated when possible. If at any time you and another student from your program wish to be paired as roommates during residential sessions please reach out at least one week in advance of your check in date. |
| If you have selected a Double Occupancy/ Shared Room at The Best Western, please indicate your agreed upon roommate's name, and any specific needs/requests. |
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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 |
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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 |