Curriculum Office Schedule Change Form
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GRU Medical College of Georgia – Curriculum Office
Schedule Change Form (SEA form)
Name ____________________________________________ Student ID # ________________ Date _______________
Cell # ____________________________
Emergency Contact Name/Phone _______________________________________
Assigned campus: Augusta __ NE __ NW __
SE __
SW __
Class of ______________
Month ____________
Drop ____________
Add ____________
Month ____________
Drop ____________
Add ____________
Month ____________
Drop ____________
Add ____________
Month ____________
Drop ____________
Add ____________
_____________________________________________________________________________________________________________________________________
Application for Off-Campus and/or Special Elective Approval
PART I
(To be completed for APPROVAL by Department that is responsible for giving grade – see list of authorized persons below.)
_______________________
MCG COURSE NUMBER ______________________ DATES OF ELECTIVE
(Minimum: 4 wks)
Have you completed all Junior Core Clerkships by beginning date of elective? YES _____
NO _____
____________________________________________________________
(If not, what core remains to be taken?) __________
LOCATION OF ELECTIVE ________________________________________________________________________________
PERSON RESPONSIBLE FOR EVALUATION ________________________________________________________________
Must include Evaluator’s contact information (phone, email):___________________________________________________________________________
MCG DEPT COORDINATOR APPROVAL ___________________________________________________________________
Satellite Campus (NE, NW, SE, SW) Approval ________________________________________________________________
ANS
S. Dawkins/Dr. J. Mayfield
BIW-2144
PATH
Courtney Sahm
CB-2930
DERM/MED
Dr. Loretta Davis
FH-100
PED
Kimberly Curtis
BG-2101B
EMER. MED
Drs. C. Fly and M. Lopez
AF 1021
PHARM
Dora Walden
CB-3623
FMP
Dayna Seymore
HB-3035
PSY
Karen Darvill
EG -3004
MED
Lizandrea Jones
BIW-5072
RADIOL
Mr. Jim Corley
BI-2225
NEU
Dr. N. Pruitt/Debbie Langston
BA-3410
SURGERY
Shannon Black
BI-4070
OB/GYN
Yvonne Booker
BA-7300
ENT
Neurosurgery
Orthopedics
Ped Surgery
OPHTH
Dr. David Bogorad
BA-2701
Plastics
Thoracic
Urology
You must return completed forms to the Curriculum Office via email
to
:
CURRICULUM@gru.edu
be officially enrolled.
Curriculum Office Only: _______ Posted in Banner _______ Posted in One45
(djt 09/11/13)
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