KSUCVM - Approval form for externship!

APPROVAL FORM FOR ELECTIVE
(EXTERNSHIP)
OFF-CAMPUS ROTATION

NO RETROSPECTIVE APPROVALS

Externship for Elective Credits

Primary Care Externship

Name:

Number of full weeks:

Dates:

Rotation:

Externship's Name/Address/E-Mail:
(Complete address)

Name:

Address:

E-Mail:

Summarize what you will be doing:

Justification:

How does this fit your future plans?

Additional Information?

Name of the doctor who will serve as evaluator:

Phone:

e-mail: