Date
Client Name
Client Phone
Email Client MUSC Email
College	-- Select from the following -- College of Dental Medicine College of Graduate Studies College of Medicine College of Nursing College of Pharmacy College of Health Professions
If CHP above Identify Program (PT,OT,PA)
Course
Course Director
Year	-- Select from the following -- 1st 2nd 3rd 4th N/A

Note: At the first supplemental group session, students are required to sign a group contract.

"Thank you for registering for supplemental instruction with the Center for Academic Excellence. We will contact you as soon as we're able to assign the small-group a supplemental instructor. We look forward to working with you soon.

-Tom Waldrep, Director