UNIVERSITY INDEPENDENT STUDY APPLICATION FORM

NOTE: Only matriculated Warner students wishing to register for an independent study in another department outside the Warner School should use this form. Students registering for ED 491 or 591 should use the Warner Independent/Field Study Application Form on Warner's website.

INSTRUCTIONS:

1. A student may register for an Independent Study if:
* student is a matriculated (accepted) student in one of Warner's degree or certification programs
* study will be completed under the supervision of a full-time UR faculty member
* student's academic record is free of incomplete or N grades (all classes must have passing grades)
* student completes and submits this form; the Warner Registrar will then register the student

2. Student should submit form before online registration closes, if at all possible, but not later than the dates below:
* Fall ~ September 15th
* Spring ~ February 1st
* Summer ~ June 1st

3. Student must follow instructions below to avoid delays in processing:
* Complete top portion of form with contact information
* Indicate offering department and select appropriate course number 491 or 591)
* Select semester, year, and enter credit hours
* Enter title; if no unique title is entered, default title will appear (i.e., Independent Study)
* In collaboration with instructor, complete the "Course Description" and "Basis for Evaluation"
* Sign and date the form

Today's Date: Today's Date: / MM / DD YYYY
STUDENT'S PERSONAL INFORMATION
Full Name (Last, First, Middle [or initial])
Nickname (if preferred)
Student ID#--if unknown, contact Warner Registrar
Must be 8 digits. Currently Entered: 0 digits.
CONTACT INFORMATION
Preferred Phone Number Preferred Phone Number - ### - ### ####
Preferred E-mail
COURSE INFORMATION
Check year/term (one each) for this registration

Check year/term (one each) for this registration 2024 2025 2026 Fall Spring Summer
Credit Hours (from 1 to 12)
Instructor's Department Affiliation (offering department)
Course Number:

Course Number: 491 (Master's) 591 (Doctoral)
Course Title (if no unique title is desired, leave blank):
Course Description (describe below the course for which you are requesting approval; include course objectives, nature of the readings or projects involved)
Basis for Grading:
SIGNATURES & APPROVALS
Student's Electronic Signature: by typing my FULL LEGAL NAME in the field below, I affirm that I wish to engage in this Independent Study as described above.

I understand this is a legal representation of my signature.
Instructor Name (student to enter name)

(Note to Instructor: your signature is required to indicate your willingness to supervise the work of the student as outlined above and to show your endorsement. Please sign and date the form in space to right, then e-mail it to the Warner Registrar.)
Instructor Email (student to enter email address)

(Please enter the instructor email address so this form can be sent to them for approval.)
Advisor Name (student to enter name)

(Note to Advisor: please sign and date the form in space to right, then e-mail it to the Warner Registrar.)

UNIVERSITY INDEPENDENT STUDY APPLICATION FORM

UNIVERSITY INDEPENDENT STUDY APPLICATION FORM

STUDENT'S PERSONAL INFORMATION

CONTACT INFORMATION

COURSE INFORMATION

SIGNATURES & APPROVALS