Please print or type the following information:

Name                                                                                  Social Security #_______________

Permanent mailing address and current phone number:

Address______________________________________________   City__________________

State                Zip                                                       Phone (     )____________________

E-mail address ________________________________

Person to contact in case of an emergency (name, relationship, and phone number):

Name                                           Relationship_______________   Phone (     )____________

My status in the last academic year was:

              medical student                       dental student                           other (please specify)

Are you currently: Enrolled in (Medical School, College, or University)            yes      no

Dean in your School to whom course grades should be directed*

Name                                                                        Title____________________________________

School___________________________________________________________________________

Address                                                                           City______________________________

State                               Zip____________________

Applicant's signature:                                                                                     Date_________________

*Each application must include a letter from the appropriate Dean of the School stating both approval to take this course and student's standing. Send application with $50.00 deposit payable to Tulane University School of Medicine prior to June 13, 2005.