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Application for Student Interest Group

Name of Student Interest Group: ________________________________________________

Brief Description of Purpose:

Goals and Objectives of Group (Please list 2 to 3):

Names, student IDs and Signatures of Four (4) Interested Students:

Please provide the name and information for a contact person in the group.

Name: ___________________________Signature: ___________________________________

Phone Number: _________________Student ID: __________ Email: _____________________

Please provide the name and contact information for the faculty advisor for this group. If

you have not already selected a faculty advisor, the Office of Student Life will assist you in

finding a faculty advisor. Please note that a permanent faculty advisor must be determined

within one academic semester.

Advisor Name: ______________________________ Signature: __________________________

Phone Number: ___________________ Email: __________________________ ____________

The following is to be completed by the Office of Student Life:

Submitted to Student Life on: _________ Approved or Denied? ___________

Signature of Counselor for Student Life: ____________________________

Signature of AVP of Student Affairs or Designee: _______________________________

PRINT NAME ID # SIGNATURE:

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