UNIVERSITY OF NEBRASKA COLLEGE OF MEDICINE
SUMMER PROGRAMS 2014
APPLICATION AND CONSENT FORM
Application Deadline: Friday preceding start of course

Section I:    To be completed by student. (Note: It is preferred to submit this form electronically and bring a signed hard copy from your institution’s administrator).

         * = Required Field

Name of Applicant :
Current Tel.:
Current Address:
Presently Enrolled at:
Address:
Permanent Mailing Address:
Permanent Tel.:
Email Address:


Course Requested:

Enrollment Request Price Course Id Course Description Credit Hr. Start Date End Date
Yes No 850.0000 GCBA 523 Medical Histology 5 06/16/2014 07/11/2014
Yes No 500.0000 GCBA 513 Human Embryology 2 06/09/2014 06/25/2014
Yes No 150.0000 GCBA 516-1w Human Gross Anatomy - 1 Week 2
Yes No 300.0000 GCBA 516-2w Human Gross Anatomy - 2 Weeks 3
Yes No 450.0000 GCBA 516-3w Human Gross Anatomy - 3 Weeks 4
Yes No 600.0000 GCBA 516-4w Human Gross Anatomy - 4 Weeks 6
Yes No 750.0000 GCBA 516-5w Human Gross Anatomy - 5 Weeks 7
Yes No 900.0000 GCBA 516-6w Human Gross Anatomy - Full Course 8 06/09/2014 07/18/2014
Yes No 750.0000 GCBA 518 Medical Neuroscience/Neuroanatomy 4 06/16/2014 07/11/2014

Reason for Taking the Course:

A separate $30 Non-refundable registration deposit is required to reserve a place in course. Your application will not be considered without this deposit. (Note: Full payment for each course is due at registration.) Please make all checks payable to: "Department of Genetics, Cell Biology and Anatomy" and mail to: University of Nebraska Medical Center, 986395 Nebraska Medical Center, Omaha, NE 68198-6395. Or Contact Tami Houdesheldt at thoudesheldt@unmc.edu for more information.