Special Permission Form
This form is to be used for courses offered as Special Permission Only. The Office of Student Affairs
must receive this form with the course director’s signature of approval during M4 scheduling so that the
information can be pre-loaded into the Optimizer for a guaranteed spot. Once the academic year has
begun, special permission courses may be requested when there is space available and the course
director signs this form.
Circle selection:
CVSU 9445
FMLY 9440
OBGY 9411
PEDS 9405
FMLY 9421
HUMS 9402
OBGY 9413
PEDS 9410
FMLY 9434
INMD 9412 (block 1-3)
OBGY 9417
PSCH 9440
FMLY 9435
OBGY 9410
PATH 9414
SURG 9440
Other_______
Name of Student:
Course Title:
(if other)
Block #:
Dates:
Duration:
From:

2 Weeks
To:

4 Weeks
Signature of
Student:
Signature of Course
Director:
Date