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2020 Mosaic Retreat Reservation Form
Questions marked with a
*
are required
Name (First & Last)
Cell Phone
Home Mailing Address
Parent/Guardian 1 Name
Parent/Guardian 1 Cell Phone Number
Parent/Guardian 1 Email Address
Parent/Guardian 2 Name
Parent/Guardian 2 Cell Phone Number
Parent/Guardian 2 Email Address
Will you be living on campus Fall 2020?
Yes
No
Undecided
If living on campus, what is your residence hall?
If living on campus, what day/time will you be checking in?
If living on campus, who will be coming with you to help move you in to your residence hall?
Do you have a zoom account set up?
Yes
No
Do you need help getting set up?
Will you have a personal lap top?
Yes
No
If you are not returning to campus and will be engaging solely online, do you have access to reliable internet?
Yes
No
Please Explain
Select the funding you are utilizing for the Mosaic fee (if applicable):
Vocational Rehabilitation (VR)
Veterans Administration (VA) Funding
Other
Please Specify
Do you feel comfortable with Mosaic staff disclosing that you are a part of Mosaic to campus partners (ex. housing, Counseling Center, University Health Services, etc).
Yes
No
During the retreat we will be hosting an optional pool party on Friday, August 14th at 6pm . Are you interested in attending?
Yes
No
If you are taking in-person classes, are you interested in a walking tour to find the specific buildings?
Yes
No
Please list any dietary restrictions (if applicable):
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