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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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