This form is to be completed by any University of Rochester medical student who is enrolling in a special elective course for academic credit. This Special Elective Drop / Add form is to be completed and returned to the Medical School Registrar's Office before participating in the experience. These forms are also located at the Medical School Registrar's Office.

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_____

Special Elective/Course Information:

Title:_____________________________________________ Location Code*:________

Course Dates:______________________________________ # Weeks:______________

Brief Description of Special Elective:_________________________________________
_______________________________________________________________________
_______________________________________________________________________

U of R Faculty Sponsor (Preceptor):____________________________ Box #:_________

Signatures:

Student:______________________________________________ Date:______________

Approval of Faculty Sponsor:_____________________________ Date:______________

Approval of Advisory Dean:______________________________ Date:______________

Approval of Registrar's Office:____________________________ Date:______________

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