Home for the Holidays – Student Registration

Name(Required)

First Last

Brock ID Number(Required)

Brock Email(Required)

Enter Email Confirm Email

Dates of Availability(Required)

Please indicate dates you are available during the Winter Break (from end of exams in December until beginning of classes in January).

Additional Information(Required)

I am allergic to pets (dogs, cats, etc.)

I am allergic to certain foods (e.g. peanuts, shellfish, etc.)

I have dietary restrictions (e.g. gluten free, vegetarian, vegan, etc.)

None of the above

Please select all that apply so we can best match you with a host family.

What types of pets are you allergic to?(Required)

What types of foods are you allergic to?(Required)

Please note specific dietary restrictions.(Required)

Additional Comments

Please include any comments or additional information here.

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