STUDENT’S NAME_________________________________________ DATE_____________ ID #_________________
(Please Print)
Return this completed and signed agreement to the Counseling and Education Support Services Department (G116
Student Center) by Friday, January 17, 2014. Once your agreement form has been completed, all fees must be paid and all necessary receipts submitted or your paperwork will not be submitted to Financial Aid for processing. If you decide to change your method of preparation after you have turned in your agreement form, you must revise your agreement form in the Counseling and Educational Support Services Office. Failure to do so may mean that you must repay any financial aid monies provided to you for your USMLE Step 1 exam preparation. Review books and other preparation aids are available for check out in the Counseling and Educational Support Services Office.
Preparation Plan – After reviewing all of your options for preparation please complete the appropriate section below and outline your plans in the space provided on page four of this agreement form. Your preparation plan must be reviewed and approved by one of the individuals listed on page four of this agreement. You are required to complete the plan for which you are approved.
KU PREP FOR SUCCESS PLAN OPTIONS
Choose one option:
_______ #1 – KU Step Prep Course:
Course dates: April 14 th -May 2 nd
$1000.00
Campus attending: Kansas City Salina Wichita
Fee includes 3 NBME exams, 3-months of USMLE World Q-Bank, live high-yield lectures, and 2 USMLE World selfassessments for small group work.
Financial Aid is available for this plan through KU Endowment or private loan.
_______ #2 – Other Live or Online Program:
Indicate on page 2 which program will be used. A calendar with your plan must be attached to this form.
Financial Aid may not be available for this plan.
_______ #3 – Self Study:
A calendar with your plan must be attached to this form.
Financial Aid is NOT available for this plan.
Questions regarding all plans should be directed to Counseling and Educational Support Services.
Payment Options for Step Prep:
Acceptable forms of payment are:
Cashier’s check, Money Order, Personal Check, Visa or MasterCard.

ONLINE PREP OPTIONS
www.falconreviews.com
Online Course Date: to:
Financial Aid is NOT available for this plan.
(Required information)
Cost: $1599.00
www.falconreviews.com
Course Dates: April 29 th -May 4 th Cost: $549.00
*Financial Aid is available for the Integrated Cases Course for the dates of the program only. Original receipt showing proof of payment required for Financial Aid reimbursement.
www.doctorsintraining.com
Online Course Dates: to: (Required information)
Financial Aid is NOT available for this plan.
www.kaptest.com
Course Dates: From: ________ To: _________ (Required information)
Financial Aid is NOT available for this plan.
Cost: $799.00
Cost: $_________
www.usmle-rx.com
Online Course Dates: to: (Required information)
Financial Aid is NOT available for this plan.
Cost: $_________
:
Course Enrolling In: __________________________________________ *
Course Dates: From: __________ To: __________ (Required information)
Course Location: _______________
Cost: $_________
*Financial Aid may or may not be available for the preparation selection indicated above.

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THIS SECTION MUST BE COMPLETED BEFORE TURNING AGREEMENT FORM INTO COUNSELING AND
EDUCATIONAL SUPPORT SERVICES BY JANUARY 17 th , 2014
#1 YES ______I am requesting Financial Aid
Check one of the following:
□ Cost of course plus living expenses
□ Cost of course only
□ Other (specify amount)$__________
Note: Original receipt showing proof of payment for course required for Financial Aid reimbursement.
#2 NO ______I am not requesting Financial Aid
STUDENT’S SIGNATURE _______________________ DATE ________________

Please specify how you are going to prepare for your USMLE Step 1 exam. Note any Question Banks, study group activities, preparation course(s), study aids, etc. that you will be using. You may complete this section in either narrative or an outline format. Please provide your target date for your USMLE Step 1 exam, knowing that you must sit for the exam on or before Saturday, May 24 th , 2014.
When you have completed this plan, please have it reviewed by one of the individuals noted below. They may provide additional guidance and suggestions based on the information that you have provided.
USMLE Step I Target Exam Date: _______________________________
PLAN:
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Only ONE of the individuals listed below must approve your plan.
Alice Carrott - (Call 8-4688 or 8-6580 for appt.)
Approved : Date__________________________
Jen Dolson - (Call 8-4356 or 8-6580 for appt.)
Approved :
Brigitte Hofmeister - (Call 8-0164 or 8-6580 for appt.)
Approved :
Date__________________________
Date__________________________
Michael Kollhoff - (Call 7-0405 for appt.)
Approved : Date__________________________