M1 Summer Research Enrollment Form

Last modified: Aug 13, 2012

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

KU School of Medicine Office of Student Affairs