SPECIAL NEEDS REQUEST FORM: 4th Year Schedule

 

Class of 2012 

 

If you have a special need regarding your 4th year schedule, please fill out and return this to the Division of Clinical Education.

 

If you have a special need and do not fill out a form, a change may not be able to be made later.  All Special Needs Requests will be reviewed by a Deans Committee.  If your request is confidential, please put the form in an envelope, mark it “Confidential Special Request” with your name on the outside of the envelope and return it to the Division of Clinical Education by the Wednesday, February 24, 2011, 4:00PM deadline.

 

DATE:

SS#:

NAME:

E-MAIL:

 

PHONE #:

SIGNATURE:

PAGER #:

 

Please check the box appropriate to your scheduling situation:

Entering 4th Year

 

Entering 4th Year with some 3rd year work to complete

 

Have been in 4th Year, graduating late  ///  Anticipated Graduation Date:

 

Returning from graduate school or Leave of Absence

 

Dual Degree Program    ////   Which program?

 

Have completed prior rotation(s) for 4th year credit

 

                        Name of rotation:

 

                        When completed

 

Scholars Program: Required to complete a senior rotation at a specific hospital

 

                        Name of hospital

 

                        Requested rotation

 

Special Requirements of Pathway?  £  Yes     £  No      If Yes,

Pathway Designated:  ___________________________________________________

Please specify special requirement as stated in the guidelines written in the Pathway:

 

 

Other (Write in.) *

 

 

*Accommodation due to disability must be supported by an Accommodation Verification Letter from the Drexel University Office of Disability Services. Requests for accommodations need to be submitted to the Office of Disablity Services. Do not provide medical documentation directly to the Dean's Office.

 

Revised 1/3/2011

 

PLEASE INCLUDE ANY ADDITIONAL INFORMATION BELOW (DETAILS HELP):