Intention to Step Out of MD Curriculum Sequence

All students planning to step of the MD curriculum sequence are required to complete this form in order to track academic progress.

* indicates required fields.

Name *








Please indicate which quarter you will step out *


Please indicate when you anticipate returning to the MD curriculum sequence *



REVIEW AND APPROVAL

All students are required to discuss their intention to step out with their Advising Dean, assigned Educator-4-CARE faculty and the information will be shared with the Assistant Directord for Medical Student Research and Scholarship to ensure that academic requirements have been met and a plan for re-entry into the MD Curriculum is established if applicable.This discussion can take place in person, by phone or over email but must take place PRIOR to the submittal of this form.

ACADEMIC ADVISING DEAN *


E4C FACULTY *