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N.O.T.E.S. REGISTRATION FORM January 16th and 17th March 6th and 7th October 2nd and 3rd (Natural Orifice Transluminal Endoscopic Surgery) Advanced courses First name. . . . . . . . . . . . . . .

LAST Name: Surname: I agree to the foregoing terms and conditions and the Student Information Form. Date of Birth: Gender: Male Female I understand I must be a U.S. legal adult to participate in this program. I understand that I certify that I have sufficient savings to cover tuition at the University of California San Diego School of Medicine and the cost of this information if required. I understand fully that I could lose my scholarship after I submit this form to the University of California San Diego. Furthermore, I understand I am responsible for all correspondence regarding this program. Furthermore, I understand that I have one (1) hour from the completion of the online coursework to meet with any member of my group regarding admission to the program. Furthermore, I understand that I am not required to participate in other online and group classes offered by UCSD Medicine, including, but not limited to, elective courses. Furthermore, I understand that I must have appropriate clearance from the U.S. Department of Health and Human Services for any insurance coverage I am aware of and that I must sign a statement indicating that I understand that I could lose my scholarship after enrollment. Furthermore, I understand all procedures and obligations and agree to provide written verification of information. Furthermore, I understand that failure to comply with any provision of this document will result in a non-renewal of my participation in this program unless otherwise provided by the UCSD administration for reasons other than failure to comply with the provisions of this document. By submitting this application I acknowledge that I have read the description of the program as well as the descriptions of other online courses offered by the University of California San Diego School of Medicine. I understand that I may only enroll at UCSD as a full-time graduate student, that my enrollment status may be reviewed at any time during the cycle of enrollment, and that the UC San Diego School of Medicine reserves the right to make changes to my status. I understand the cost of this information is one and one-half (1½) times the current UCSD Resident Fee as outlined in the Annual Fee Schedule for Graduate Medical Education. Furthermore, I understand that payment of the above-noted charge will result in the cancellation of my current enrollment in the University of California San Diego School of Medicine Graduate Medical Education program. Furthermore, I understand that I have one hundred thirty (120) student hours of UC San Diego School of Medicine coursework to complete.

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