*Address 1
  Address 2
*Email Address
  Phone Number 

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In addition to sleeping, do any of these activities take place in the area?


Type of bedroom
Studying Yes No
Sitting Yes No
Sewing Yes No
Snacking Yes No
Television viewing Yes No
Listening to music Yes No
Telephoning Yes No
Dressing, makeup, etc. Yes No
Reading in bed Yes No
Sleeping during daylight hours Yes No
Lightproof window coverings needed Yes No
Other activity

Type of bedding preferred

Twin bed How many
Double bed How many
Queen-size bed How many
King-size bed How many
Mattress: regular soft extra firm
Water bed size
Special requirements