STUDENT NAME:

DATE:

This completed form (including necessary faculty signatures) must be filed with the Years Three and Four Registrar in the Office of Education and Curriculum NO LATER than FOUR (4) WEEKS BEFORE the course start date.  If this is not done, no schedule change will take place.

Extenuating circumstances, if submitted in writing, will be reviewed by the Chair of the Year Four Curriculum Committee.

* * * * * * * * ADD / DROP * * * * * * * * *

____ ADD ____ DROP

 Dates

Week #s

ELECTIVE

Elective Faculty Signature

Date

(NOTE: Faculty are under no obligation to approve last minute changes.  Any changes received after the deadline will not be reflected on the final class roster.)

* * * * * * * S W I T C H * * * * * * *

SWITCH ELECTIVE

FROM:

Dates

Week #s

TO:

Dates

Week #s

Elective Faculty Signature

Date

(NOTE: Faculty are under no obligation to approve last minute changes. Any changes received after the deadline will not be reflected on the final class roster.)

PLEASE RETURN THIS FORM TO:

DEADLINE:  FOUR (4) WEEKS PRIOR TO THE START OF THE ELECTIVE

Cherie Forsyth , Years Three & Four Registrar

SIU School of Medicine

Office of Education & Curriculum

801/3 N. Rutledge, PO Box 19622

Springfield, IL 62794-9622

Phone: 217/545-6124 Fax: 217/545-0192

 Date Received: _____________________