Physician Assistant Preceptor Form

Name*

First Last

PC ID#*

PC Email*

Cell Phone*

Gender*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Summer Housing Needs

I am…*

NOT requesting campus housing (commuter student).
requesting housing for summer school.
requesting housing for reasons other than summer school

Summer Living Address*

Which Summer School Sessions?*

Summer Session 1
Summer Session 2
Both Summer Sessions

Do you have a request for a specific roommate?

No
Yes

Roommate Name

With what program are you working?*

Agreement to Summer Housing Terms*

Agree

By submitting this form, I understand that I will be assigned to a space in the summer housing I have requested and will be billed accordingly. I understand that I am responsible for checking in and checking out at the scheduled times. I agree to abide by all policies and procedures listed in the Garnet Book and distributed by Presbyterian College and recognize that failure to follow policies and procedures may result in Student Conduct Charges and/or removal from summer housing.