Registration Form

Name of Interest Group:

Date:

mm/dd/yy

Group Focus (please check one):

Cultural / Diversity

Academic

Sports

Other (please explain)

If other, please explain:

Mission Statement :

Monthly Activities:

Event(s) Sponsored by group (if any):

FACULTY ADVISOR Contact Information:

Name of Faculty Advisor:

Program (Department):

E‐Mail address:

Phone Number:

GROUP CONTACT INFORMATION (Primary and Secondary contacts are required)

Primary Contact:

Name:

E‐Mail address:

Phone Number:

Secondary Contact:

Name:

Phone Number:

E-mail Address:

Membership inquiries should be directed to (please check one or both):

Primary Contact

Secondary Contact

No group or organization can deny consideration for membership to any student because of sex, race, religion, creed, national origin, handicap, sexual orientation, gender identity, or marital status. The Office of Academic and Student Affairs is not responsible for the recruitment of members or the development of club activities. The club is solely responsible for funding and expense issues.

Submitted by:

Date:

mm/dd/yy