PRISM HOSPITALITY HOUSE FLEXIBLE STAYS APPLICATION
1. BASIC PERSONAL INFORMATION
1a. Title
*
1b. Applicant Name
*
First Name
Last Name
1c. English Name
If different from First Name
1d. E-mail
*
example@example.com
1e. Gender
*
Male
Female
1f. US Phone Number
Format: (000) 000-0000.
1g. Country of Origin
*
1h. Are you an international student or visiting scholar? Which school in Pittsburgh do you attend?
*
2. INFORMATION ABOUT YOUR STAY
2a. Purpose of Visit:
*
Please state the purpose of your stay at the PRISM House
2b. Check-in and Check-out Date (Note: Check-in time is between 9 am-10 pm)
*
2c. Will there be another person staying in the room during the period? (No unmarried couples will be allowed to share a room.)
*
Yes - answer the following questions in Section 2
No - go to Section 3
2d. Name of Additional Person
First Name of Additional Person
Last Name of Additional Person
2e. Gender of Additional Person
Male
Female
2f. Relationship to you
Please fill in the blank if you have additional person staying in the same room.
2g. Please provide the dates of stay for the additional person.
3. EMERGENCY INFORMATION
3a. Emergency Contact Person
*
First Name
Last Name
3b. Relationship to You
*
3c. Emergency Contact Phone
*
-
Country Code
-
Area Code
Phone Number
4. LIABILITY, TERMS AND CONDITIONS
4a. I certify that I have my own health &/or travel insurance.
*
Yes
No
4b. Please carefully read the PRISM House rules at the link below.
*
4c. Please review your response and sign before submitting.
*
Submit
Please wait for the application approval before proceeding to the payment. Our staff will contact you shortly. QUESTIONS? Contact Scott Boyd: scott@prismpgh.org
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