This form is to be completed for formal University of Rochester School of Medicine and Dentistry electives, clerkships, externships, and courses listed that are offered to matriculated medical students. Medical students who are enrolling in special elective courses or extramural electives are required to complete either a Special Elective Drop/Add Form or the Extramural Elective-Clerkship Drop/Add Form before participating in the experience. These forms are also located at the Medical School Registrar's Office.

Student Name________________________ Student ID Number________________

Box #__________ Class of__________ Local Phone_____________________________

(Check One) First Year_____ Second Year_____ Third Year_____ Fourth Year_____ Other_____

Action to be taken: Add_____ Drop_____ Date Change_____ Location Change_____

Elective/Clerkship/Course Information:

Course #:_______________ Location Code*:_______________

Course Title:_____________________________________________________________

Course Dates:____________________________________________________________

U of R Faculty Sponsor (Preceptor):_________________________ Box #:____________

Signatures:

Student___________________________________________ Date__________________

Approval of Faculty Sponsor___________________________ Date__________________

Approval of Advisory Dean___________________________ Date___________________

Approval of Registrar Office___________________________ Date_________________

*   Location Codes: SMH, TGH, RGH, STM, HH, MCH, FAM MED, PRO (Private Office), or O (Other)