| First Name | |
| Last Name | |
| Ohio University PID Number | |
| Your E-Mail Address | |
| Alternate E-Mail Address |
If you are working with an agency, you can provide the agency's e-mail address and your personal e-mail address above. An e-mail will be sent to both e-mail addresses entered above. |
| Your Phone Number (xxx) xxx-xxxx | |
| Gender | Male Female |
| Interim Session |
Winter Break |
| Date of Checkin | + See Note Below |
| Date of Checkout | + See Note Below |
| I will bring my own linens and towels |
|
| I would like to purchase a linen packet ($40) | |
| I need an ADA compliant room | |
| Special Needs | |