Applicant Name:* must provide value
Please provide your first and last name.
Applicant Email:* must provide value
Applicant Phone Number:* must provide value
Academic Year* must provide value
(example: 2016-2017)
Former Name of Organization
Name of Student Organization:* must provide value
Note: A student organization may not use VCU or MCV directly in the name of the organization because this might imply sponsorship. Example: MCV Student Free Clinic is NOT allowed. Student Free Clinic at VCU is CORRECT
Student Organization Email Address: * must provide value
Purpose of Organization:* must provide value
Classify your Organization:* must provide value
New
Renewal
Re-activate
Select one option.
Eligibility requirements for officers and members of a Student Organization (student interest groups, SIG):
1) List 4 members - must be a full time VCU student and actively enrolled in the School of Medicine. You must list two officers (minimum) - It is recommended that your organization has a president and a treasurer, as well two additional members.
2) The registration form must have all signatures to be processed.
3) While it is not mandatory to have a Faculty/Staff Advisor, it is highly recommended. While it is not mandatory to have established By-Laws or a Constitution,
it is highly recommended. If your group has either of these documents, please
provide a copy with your registration form.
An appointed officer who is unable to fulfill his/her obligations and/or duties for any reason
during the academic school year should contact the office of Student Affairs and other
officer(s)/member(s) of the organization. Any financial data and/or banking
documents should be turned over to his/her fellow member or a staff member of the
Student Affairs Office.
Please Agree to and Acknowledge this requirement.
* must provide value
I Agree and Acknowledge.
I Disagree and do not Acknowledge.
Select one option
Officer #1 Name:* must provide value
Please provide the first and last name.
Officer #1 Title:* must provide value
Officer #1 Email:* must provide value
Officer #1 Local Address:
Officer #1 Phone Number:
Advisor Name:
Please provide the first and last name.
Advisor Email:
Advisor Phone Number:
Is the Advisor a part of VCU faculty/staff? Yes No
Officer #2 Name:* must provide value
Please provide the first and last name.
Officer #2 Title:* must provide value
Officer #2 Email:
Officer #2 Local Address:
Officer #2 Phone Number:
Officer #3 Name:
Please provide the first and last.
Officer #3 Title:
Officer #3 Email:
Officer #3 Local Address:
Officer #3 Phone Number:
Officer #4 Name:
Please provide the first and last name.
Officer #4 Title:
Officer #4 Email:
Officer #4 Local Address:
Officer #4 Phone Number:
How many interested members do you currently have?* must provide value
Member #1 Name:
Please provide the first and last name.
Member #1 Email:
Member #2 Name:
Please provide the first and last name.
Member #2 Email:
Is your organization open to all VCU students (medical, nursing, PT, pharmacy, etc.)?* must provide value
Yes
No
If no, please specify
Are there any membership requirements specific to your organization (ex: application process,
membership dues, etc.)? * must provide value
What are some small or large-scale event ideas that you have in mind? This includes events,
service projects, fundraisers, etc.* must provide value
If/when you become approved, you will have the option of requesting funding from the University.
What are some things your organization will want/need if funded?* must provide value
Will this organization have affiliation, now or in the future, with any local, regional, national,
or international organization? If Yes, please name and describe affiliation. If no, please write No.* must provide value
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Officer #1 Signature:* must provide value
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Advisor Signature:
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Officer #2 Signature:
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Officer #3 Signature:
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Officer #4 Signature:
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Member #1 Signature:
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Member #2 Signature:
I affirm that the information contained on this request is true and correct to the best of my knowledge.
Applicant Signature:* must provide value
Submit
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