Completing and submitting this Enrollment Request form is your opportunity to schedule courses for spring of your senior year. Choose from Electives, Critical Care Selectives, and Subinternships(click on catalog link below). Your Health of the Public course should already be scheduled for November, February, or April (check your print-out).

Your Rural Preceptorship must be arranged through either Family Medicine, Internal Medicine, or Pediatrics. To schedule your rural experience: 1) go to department; 2) work out details, and; 3) complete an add slip in ASA. Special arrangements are necessary for away, “Special Programs” (talk to Melanie in ASA).

In October, I will place a document in your mailbox outlining the courses you have completed, ones you currently have scheduled, and ones you still need to schedule for completion of graduation requirements.

On the form below, indicate your first and second choice of courses for each month (including free time, if that is what you wish for a specific month).

Each request has a drop down menu so you may choose the course and dates. If your first and second choices are two two-week courses, please indicate whether you wish both or only one of the courses by choosing “AND” or “OR” (this field defaults to “OR”) If the course you are interested in, does not appear in the drop down menu, list your request in the “Explanation” section. The course name may not be what you expect, or that specific course may not be offered. Use the link to the course catalog to view course listings and descriptions.

In the “Explanation” section below, you can indicate additional months that might be acceptable for a specific course, as well as additional courses that might be acceptable for specific dates. Explain the details and reasons for your choices in this section.

The last section is an option to request an elective on the Kansas City campus. Please include course, month, faculty (if applicable). Also include a 2nd choice month.

Worksheet Form
KU Med Catalog

*Required Fields

*First Name:
*Last Name:

January 1.Course Request:	(Department / Course Number / Course Name)
Date Request:
	Or And
January 2.Course Request:	(Department / Course Number / Course Name)
Date Request:
Explanation:

February 1.Course Request:	(Department / Course Number / Course Name)
Date Request:
	Or And
February 2.Course Request:	(Department / Course Number / Course Name)
Date Request:
Explanation:

March 1.Course Request:	(Department / Course Number / Course Name)
Date Request:
	Or And
March 2.Course Request:	(Department / Course Number / Course Name)
Date Request:
Explanation:

April 1.Course Request:	(Department / Course Number / Course Name)
Date Request:
	Or And
April 2.Course Request:	(Department / Course Number / Course Name)
Date Request:
Explanation:

May 1.Course Request:	(Department / Course Number / Course Name)
Date Request:
	Or And
May 2.Course Request:	(Department / Course Number / Course Name)
Date Request:
Explanation:
Kansas City Campus Elective Request	(Please include all pertinent information and 1st and 2nd choices for months)

This form is a request that we hope to enroll you in for your spring schedule. If we are unable to accommodate any of your requests we will contact you for additional choices. Please submit this Spring Enrollment Request form by 5:00 PM, November 2, 2009.

(Your request will be sent to Melanie Runge via e-mail. You may print off the confirmation page for your records)

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