Department of Neurobiology and Anatomy Summer Remediation Course Registration

Please fill out the following information and click on the "submit" button when you have finished. You will then receive instructions on how to access additional registration material. This will include a consent form that must be signed by the Administrator who has agreed to act as contact person at your institution (usually a Dean of Student Affairs), and instructions regarding payment, which can be made either by check or credit card. No refunds will be given after the course begins.

NOTE: YOUR COMPLETED REGISTRATION (INCLUDING PAYMENT) MUST BE RECEIVED BY FRIDAY JUNE 7th, 2024.

Courses registration:

Section I: Student information

Please Complete ALL Information Below for Registration. All fields with asterisk * are required to proceed.

Applicant Last Name:^*

Applicant First Name:^*

Student ID:^*

at your institution

Current Telephone #:^*

Email address:^*

Address

Street Address:^*

Address (cont'd):^*

City/Town:^*

State:^*

Zip (Postal Code):^*

Educational institution

Presently enrolled at:^*

Enrolled program degree:^*

MD, DO, DVM, DDS, post-bacc, etc.

Name & Address of Institution Administrator

Administrator Name:^*

Institution Street Address:^*

Address (cont'd):^*

City/Town:^*

State:^*

Zip (Postal Code):^*

Admin. Telephone #:^*

Admin. Email address:^*

Section II: Courses

^*Additional charges may apply for courses taken outside of the normal schedule.

Course Name	Fee	Start Date	End Date
Medical Gross Anatomy	$2,200.00	6/10/2024	7/16/2024
Medical Embryology	$1,100.00	6/10/2024	6/24/2024
Medical Microanatomy	$2,200.00	6/10/2024	7/12/2024
Medical Neuroscience	$2,200.00	6/10/2024	7/12/2024

* A $600 discount will be applied when taking two or more courses.

Reason for Taking the Course:^*