Cottage and Apartment Request Form

Agreement - Please Read

In requesting this reservation, I agree to abide by the rules and regulations stated above of the UVA Medical Alumni Association and Medical School Foundation. I will treat the property respectfully and report any damage or breakage during my stay. I agree to accept full liability for any damages caused by me or members of my family. I understand that MAA/MSF has the right to terminate this reservation at any time for non‐compliance of stated terms or for abuse of the property.

Please indicate if you agree to the above rules and regulations:*

I agree
I disagree

Personal Information

Full Name of Alumnus/a*

Class Year*

Preferred Street Address*

Preferred City/State/ZIP*

Preferred Email*

Preferred Phone Number*

Cell Phone Number (If different than preferred)*

Below, please list the names of any accompanying family members or guests staying in our cottage or apartment during your visit. There is a single size cot available to be set up by request. Because of the age and layout of our building, we cannot accommodate children under the age of 12 years. Also, because of allergic reactions for some guests, we respectfully request that you not bring your family pets with you during your stay. We also have a no smoking policy for all buildings and grounds. Thank you for your cooperation.

Accompanying Spouse/Guest Full Name

Additional Family Member

Will you need the single cot set up for use during your stay?*

Yes
No

Reservation Information

Requested check-in date*

Requested check-out date*

Would you like to request an early check in or a late check out? If yes, please specify your needs.

Please indicate if you have a preference for the cottage or the apartment. Note: This is not guaranteed and depends on availability.*

Apartment
Cottage
No preference

Will you have a vehicle with you? (We can provide up to two spaces per reservation.)*

Yes, my personal vehicle
Yes, a rental vehicle
No

Please indicate the make/model and license plate of your vehicle(s) below.

Please indicate the nature of your visit:*

Personal
Business
Both personal and business

Emergency Information

Emergency Contact's Name*

Relationship*

Address*

Phone Number*

Additional Questions/Comments

Please list any questions you may have about your reservation here

Resources For...

Students

Alumni

Housestaff

Faculty