David Geffen School of Medicine at UCLA

Visiting Student Questionnaire
If you are interested in finding a roommate, please complete this form and submit electronically.
Create a Password:
NOTE: This will be used to later edit or delete your information in the database. Required.
First Name:
Last Name:
Current Address:
Current Address (cont.):
City:
State:
Zip Code:
NOTE: Please use this format (xxxxx or xxxxx-xxxx)
Telephone:
NOTE: Please use this format (xxx-xxx-xxxx)
E-Mail Address:
Gender:
Type of Housing:
Where would you like to live?
NOTE: Some surrounding cities include Westwood, Santa Monica, West Los Angeles, Palms/Marina Del Rey, Brentwood, Hollywood, Culver City.
Date you would like to move:
NOTE: Please use this format: mm/dd/yyyy
Maximum rent you are willing to pay:
NOTE: Use only numbers, no dollar sign ($)
Would you be willing to share a room? Yes No
Do you smoke? Yes No
Do you have pets? Yes No
Do you have a significant other who may be visiting often? Yes No
Comments:
NOTE: Please use this field to describe yourself or any other information that you feel may be valuable.
By pressing the submit button below, I authorize the release of the above information to students of the David Geffen School of Medicine at UCLA.