Internal Electives - UMass & affiliates

Elective schedule changes can only be made with written consent of the Elective Coordinator, your House Mentor (on your PEP) and the Associate Dean for Student Affairs. Two months notice is required when dropping an elective. An exception may be made for extenuating circumstances.

Students: Please fill out Section , save the file using your name as the file name (e.g. joesmith.doc) to your hard drive**. Request up to 3 time choices per elective – use the drop down menu for Block field. Use the top block to ADD an elective and the bottom section if you’re requesting to DROP an approved elective. Create an e-mail, attach the saved internal elective form and forward it to the Elective Coordinator to complete Section . If the elective is on your PEP, you're done! If the elective is NOT on your PEP, you must file an amended PEP which shows this elective. When we receive the completed form from the Elective Coordinator, we will send you a copy via email so you will know whether you were approved for the elective and when / whom to report to. Senior Scholars: You must complete a separate Elective Application Form for each month you want to receive credit for.

Note: To move a rotation from one block to another, first drop the elective in the DROP section (with the original dates), then add the elective in the ADD section with the requested dates. The Elective Coordinator will put his/her name and check the appropriate box in both sections.

Elective Coordinators:Please fill out areas designated Section  with your name and check whether you approve “Yes” or disapprove “No” the requested elective / elective change and which Block / Date Choice you've approved the elective for. For your convenience, the 'Block' field has a drop down menu. If the elective is approved, fill in the  "Student should report to" section. If this is an add / drop, your elective will be listed in both sections; repeat this procedure for both sections. Save the document to your hard drive**, create an e-mail and attach the updated & saved form to the e-mail. E-mail the completed form to: .

INTERNAL unlisted ("design your own") elective: If the elective is not listed in the elective syllabus, you must also send an email with a description of the elective to together with this form.

** If the document opens in a web navigator page (Explorer or Netscape) you can still save it as a Microsoft Word Document (.doc) in the Save As… menu by selecting Microsoft Word as the file type and/or by ending the file name (which will be your name) in .doc

Student Name: Pager #: Class of: Date: 12/16/13

(Elective Coordinator)

ADD
Elective / Add / Start Date/Choice
(m/d/y) / 4-week Block Choice / 2-week Block Choice / Coordinator Name / Approval
Yes No / Approved in
Elective is Select #1234 weeks
Course No:
Course Name:
Site: / 1st:
2nd:
3rd: / 1st: ???E1E2123456789101112
2nd: ???E1E2123456789101112
3rd: ???E1E2123456789101112 / Dates:
Block #: / Block ???E1E2123456789101112
or
Time

Student should report to:

(Elective Coordinator)

DROP
Elective / Drop / Start Date/Choice
(m/d/y)) / 4-week Block / 2-week Block / Coordinator Name / Approved
Yes No
Elective is Select #1234 weeks
Course No:
Course Name:
Site: / Block: ???E1E2123456789101112 / Dates:
Block #:
Please provide a reason for dropping this elective:

Associate Dean for Student Affairs:

Revised 12/2013