New Student Organization Application
Proposed Organization Name:
Your answer
Date of Submission
MM
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DD
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YYYY
Name/Email of Individual(s) who completed this application:
Please use your mednet email account***
Name:
Your answer
Email:
Your answer
Name:
Your answer
Email:
Your answer
Name:
Your answer
Email:
Your answer
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.

Section 1. Mission Statement
Student Organizations extend medical education beyond the classroom by providing all UCLA medical students with the opportunity to explore careers in medicine, participate in national medical organizations, stimulate interest in medical issues, and develop leadership and medical advocacy skills.
Use this space to include a description of your organization and how it fulfills the general mission above. Please limit your response to 500 words or less. Bullet point format preferred.
Your answer
Section 2. Proposed Leadership***
Each group must have the following:
1. 1 or 2 Head Coordinator Positions
2. Supporting Coordinator Positions (Optional)
3. One upperclassman (MS2 or MS4) Student Advisor
4. One faculty advisor (Residents & Fellows are not considered faculty)

***Please keep in mind that students must be in good academic standing and must abide by the honor code. Also, students can accept a Maximum of 2 head coordinator positions or 1 head coordinator and 1 elected MSC position. If you plan on accepting a supporting coordinator position in addition to the 2 head/MSC positions, please speak with Mary Ann in the SAO.***

Propsed Leadership (Type in names)
Your answer
***Please enter the names and contact information for the roles described below. In addition, your faculty must sign the attached Faculty Advisor Acknowledgement Form, which you must submit with your application.***

(All final approval of positions will be made by Dr. Miller)

Head coordinator/President (please list all co-coordinators/presidents)
Name:
Your answer
Position/Title
Your answer
Phone #
Your answer
Name
Your answer
Position/Title
Your answer
Phone #
Your answer
Supporting Leadership (VP, executive board, commitee chairs, etc.) if more than 5 supporting leaders, email Mary Ann (mtriest@mednet.ucla.edu)
Name
Your answer
Position/Title
Your answer
Phone #
Your answer
Name
Your answer
Position/Title
Your answer
Phone #
Your answer
Name
Your answer
Position/Title
Your answer
Phone #
Your answer
Name
Your answer
Position/Title
Your answer
Phone #
Your answer
Name
Your answer
Position/Title
Your answer
Phone #
Your answer
Name
Your answer
Postition/Title
Your answer
Phone #
Your answer
3rd of 4th Year Student Advisor(s)
Name
Your answer
Postition/Title
Your answer
Phone #
Your answer
Name
Your answer
Postition/Title
Your answer
Phone #
Your answer
Faculty Advisor(s)
Name
Your answer
Department
Your answer
Email
Your answer
Name
Your answer
Department
Your answer
Email
Your answer
If applicable, please list the National/Regional Organization Contact Person
Name
Your answer
Email
Your answer
Title
Your answer
Section 3. Proposed Events
All organization are required to hold 3 events for the year. One collaborative event, one non-lunch talk event of choice.Please be aware that you are required to hold at least one of these events in the fall and one in the spring. The MSC will determine whether the MSC will determine whether the events you listed are viable and meet the qualifications for approval.
Event: #1
Proposed Event Title #1
Your answer
Proposed Date
MM
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DD
/
YYYY
Proposed Speaker if Applicable
Your answer
Type of Event
Your answer
Proposed SIG Collaborator
Your answer
Detailed Description of Event (2-3 Sentences)
Your answer
Event: #2
Proposed Event Title #2
Your answer
Proposed Date
MM
/
DD
/
YYYY
Proposed Speaker if Applicable
Your answer
Type of Event
Your answer
Proposed SIG Collaborator
Your answer
Detailed Description of Event (2-3 Sentences)
Your answer
Event: #3
Proposed Event Title #3
Your answer
Proposed Date
MM
/
DD
/
YYYY
Proposed Speaker if Applicable
Your answer
Type of Event
Your answer
Proposed SIG Collaborator
Your answer
Detailed Description of Event (2-3 Sentences)
Your answer
Section 4. Policies
***This section must be completed by proposed leadership and all areas must be checked off***
Funding Policy
Attendance Policy
Food Policy
Travel Policy
Supply Policy
Items that are NOT funded by the MSC
By checking off the boxes above and typing my name below, I (We) acknowledge and agree to abide by the Policies above.
Your answer
Section 5. Faculty Advisor Acknowledgement
Student Interest Group
Your answer
Proposed Leadership
Your answer
Faculty Advisor Eligibility:
Required Duties:
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.)
Name
Your answer
Position/Title
Your answer
Phone or Pager
Your answer
Email
Your answer
Name
Your answer
Position/Title
Your answer
Phone or Pager
Your answer
Email
Your answer
Department
Your answer
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.
Name of Faculty Advisor
Your answer
Date
MM
/
DD
/
YYYY
Name of Faculty Advisor
Your answer
Date
MM
/
DD
/
YYYY
Mark this box if your group plans or participates in health fair (A Health Fair is any event that provides health promotion, education, and/or screening activities)
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