M1 Summer Research Enrollment Form

First Name
Last Name
KUID
Email
Course Number   Example: IDSP 800
Credit Hours   2 OR 4
Beginning Date  Format: dd/mm/yy
Ending Date   Format: dd/mm/yy 
Location
KUMC, VAMC, Other (Hospital, City, State)
Full name of supervisor/evaluator
Supervisor/evaluator's telephone number
Fax # of supervisor/evaluator (optional)
Email address supervisor/evaluator

Enrollment approved by  
 

Last modified: Feb 25, 2014
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