Co-Curricular Requirements Credit Request Form

Complete the following form to receive credit for participating in co-curricular activities. Each academic year (P1, P2, & P3), you are required to participate in (3) co-curricular activities and complete (7) hours of service learning. During your P4 year, you are only required to complete (1) co-curricular activity.Your co-curricular activity must fall into each of the (8) Domains at least once throughout your enrollment in the program. You can only select (1) Domain per form.

Name*
First Last
T-Number*
Phone*
School Email*
Personal Email*
Domain Dropdown List*
Professional Year*
Name of the Event*
On Site Preceptor*
Event Date/*
Date Format: MM slash DD slash YYYY
Time*

: HH

MM
Description of Event*
Your Reflection*
File
Signature*