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 *

First

Last

Student ID *

Email *

Phone *

Current Year *

Reason for stepping out *

If you selected 'Other' for any of the categories above please explain your reason for stepping out

Please indicate which quarter you will step out *

Autumn

Winter

Spring

Summer

Academic Year *

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

Autumn

Winter

Spring

Summer

Academic Year *

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 *

I acknowledge that I have discussed my plans with my Advising Dean and they are in support of my stepping out of the MD curriculum.

Academic Advising Dean Name *

E4C FACULTY *

I acknowledge that I have discussed my plans with my E4C faculty and I will require a 'Clinical Skills Maintenance Plan' during my time out of the MD curriculum sequence.

I acknowledge that I have discussed my plans with my E4C faculty and I will NOT require a 'Clinical Skills Maintenance Plan' during my time out of the MD curriculum sequence.

E4C Faculty Name *