Name:  *Select Student Name Adams, Mark Ali, Nadia Andruska, Adam Baker, Teresa Bloom, Andrew Buecker, Tony Bunch, Jennifer Carter, Melinda Cheema, Asmaa Chia, Benjamin Chihade, Deena Christiansen, Peter Cohen, Blake Crowner, Jason Deem, Daniel Dial, Samantha Doerr, Danielle Doolittle, Othniel DuBois, Kimberly DuMontier, Erin Durkin, Rebecca Echeazu, Chinelo Farley, Norah Fisher, Marita Frederick, Luke Freund, Meghan Fultz, Julie Gordon, Tandra Hayes, Sean Henry, Drew Hinzman, Justin Hutto, Justin Jones, Brent Kearns, Bethany Khatibi, Esther King, Adam Kirkwood, Dawn Kotal, Eric Kyte, Natasha Le, Minh-Bao Lindorfer, Christi Lockhart, Kerri Luong, Benjamin McEnerney, Laura Meder, Irene Mendoza, Julie Meyerholz, Andy Milburn, Suzanne Moja, Ashley Mompremier, Emerson Park, Hannah Parkin, Annie Pham, Quoc Pope, David Radford, Lee Reed, Matt Regnier, Holly Richards, Kate Rigdon, Jillian Rodos, Adam Rose, Jennifer Roth, Valerie Rubenacker, Sara Ruthman, Carl Sanford, Tifani Schafer, Erin Shah, Lisa Shah, Neil Shakir, Shariff Sheffer, Doug Simpson, Clint Sinha, Michael Slater, Chris Spence, Tisha Stelle, Lacey Sterrett, Mary Stock, Ryan Suprenant, Suzanne Thompson, Katie VanderWaal, Adam Vasquez, Kelly Weitzel, Bob Wold, Brittany Woods, Teschlyn Young, Justin zztest                   Advisor:  - SELECT ADVISOR NAME - *Other Hossam Abdel-Salam, MD Robert Abrams, MD Kabiyadi Acharya, MD Tom Ala, MD Janet Albers, MD Tracy Aldridge, MD Edward J. Alfrey, MD Amber Barnhart, MD Joseph Basler, MD Craig Batterman, MD Beau Batton, MD Gregory Bennett, MD Jeffery Bennett, MD Careyana Brenham, MD Reginald Bulkley, MD David Decker, MD Gary Dunnington, MD Rodger Elble, MD, PhD M. Steven Evans, MD Maureen Francis, MD Mark Francis, MD Stuart Frank, MD Jason French, MD Keith Gabriel, MD Christopher Gleason, MD John E. Godwin, MD David Griffen, MD Susan Hingle, MD Gary Horowitz, MD Gary Johnson, MD Janak Koirala, MD Regina Kovach, MD Kathy Lake, MD Harald Lausen, DO Scott Long, MD Tracy Lower, MD Fritz Lower, MD Chris McDowell, MD Wesley McNeese, MD Tracy Milbrandt, MD Michelle Miner, MD Sumanta Mitra, MD Robert Mocharnuk, MD John E. Murphy, MD Charles Neal, MD Erica Nelson, MD Matthew Peecher, MD Michael Pranzatelli, MD Mark Puczynski, MD Don Ramsey, MD David Resch, MD Gary Rull, MD Leonard Rybak, MD, PhD Hilary Sanfey, MD Ross Silverman, JD David Steward, MD Ted Sunder, MD Cynthia Thomas, MD Andrew Varney, MD Zeng Wang, MD, PhD Elvin Zook, MD

Your Neurology Clerkship rotation has already been selected and other requests will work around that course.  Also, in the spaces below, please note any SPECIFIC TIME REQUIREMENTS, i.e. clerkship deferrals/remediations that you have to make up, Pending Off-Campus dates that you are sure of, Individually-Designed and Research Electives, and Vacations.  Use the Week # and Date guide above to list time requirements in this space.  Do not # these as priorities.

Using the lines provided next to the priority numbers, list IN ORDER OF PRIORITY, not chronological order, those catalog electives you wish to take along with the length of time desired in weeks. (See completed example form copied on pink paper.)

Program Selection (Choose One):

Specialty Pathway Choose Pathway Family & Community Medicine Internal Medicine Obstetrics & Gynecology Pediatrics Psychiatry Population Health Surgery: General Surgery Surgery: Otolaryngology/Head & Neck Surgery Surgery: Orthopedic Surgery Surgery: Plastic Surgery

Undeclared

This registration request meets the requirements for the fourth year elective program as stated in the elective policy for the Class of 2009.

CHECK YOUR NUMBERING.  You can only have one 1st priority, one 2nd priority, etc.  Forms with numbering errors may cause a delay in scheduling your courses.  Course numbers ending with :  1 indicates half-time mornings only; 2 indicates half-time afternoons only; 3 indicates full time; and courses ending in a 4 indicates Thursday afternoons (extended).

Please provide any other notes or information that you would like to have considered when your schedule request is entered:

NOTE:  Before clicking on the "submit" button, please print a copy of this form!