University of Rochester

Name: Phone:

Student ID: E-mail:

Address:

A) I am notifying you that I will be taking my originally approved course(s), but not during the term(s) I originally planned to. My new plan is to take the course(s) in the term(s) and year(s) listed below.

(Please provide course numbers only, e.g. MTH 161)

Course: Original Term: New Term:
Course: Original Term: New Term:

B) I would like to replace a previously approved course with a different course.

(Please privide the course numbers and titles and term, e.g. MTH 161, Calculus 1A, Spring 2007)

ORIGINAL
Course Number: Title: Term:
NEW
Course Number: Title: Term:

1. Why is the change necessary?
a) Orginal course cancelled
b) Time conflict
c) Other (describe):

2. Please describe how and why the new course will enhance or maintain your original Take Five proposal:

Please enter the two words you see below into the yellow box before submitting your form.