| 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 |
|
| |
|
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