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New Student Organization or Student Interest Group Application

This application is used to obtain official recognition as a Student Organization. Applications for New Student Organization recognition may be submitted at any time. If you have any questions about any section of the application, please email Mary Ann Triest at mtriest@mednet.ucla.edu.
This question requires a valid date format of MM/DD/YYYY.
calendar
Name/Email of Individual(s) who completed this application (please use your mednet email account): *This question is required.
Please enter the names and contact information for the roles described below. In addition, your faculty must sign the Faculty Advisor Acknowledgement Form, which you must submit with your application.

(All final approval of positions will be made by the SAO)
*required

Head coordinator/President(s)

Supporting Leadership (VP, executive board, commitee chairs, etc.) If there are more than 5 supporting leaders, email Mary Ann an excel sheet with names and position titles (mtriest@mednet.ucla.edu).
MS3 or MS4 Student Advisor(s)
Faculty Advisor(s)
*required
If applicable, please list the National/Regional Organization Contact Person
4. Proposed Events
Career specialty interest groups (CSIGs) are required to hold 3 events for the year, non-CSIG's are required to hold one event per year. For CSIG's, one must be a collaborative event with another student org, one must be a non-lunch talk event of your choice. Please be aware that CSIGs are required to hold at least one of these events in the fall and one in the spring. The MSC will determine whether the events you listed are viable and meet the qualifications for approval.

EVENT #1
EVENT #2
EVENT #3
6. Faculty Advisor Acknowledgement
Faculty Advisor Eligibility:
Required Duties:
We expect faculty members to
Faculty Advisor: Please complete the faculty advisor information section below. If there are multiple advisors, both need to complete the form and both advisors need to sign in the designated area below. (email, pager, location etc.)
By checking the area above and signing below, I confirm that I am eligible to serve as faculty advisor for the student organization identified above and am willing and able to complete the required duties that come with the position. I have met with the organization leaders and I have reviewed the renewal application and the policies and procedures the organization leaders must follow.
7. Does your student group plan to participate in a health fair? (A Health Fair is any event that provides health promotion, education, and/or screening activities)
8.

Please indicate if you are a cultural affinity group and would like to participate in Cultural Awareness Week and other activities planned by the Diversity, Inclusion, and Outreach (DIO) office.