The University of Texas Health Science Center at Houston

Application for Recognition as a School-Based Student Organization

See UTHSC-H Policy 1.18 UTHSC-H Student, Faculty or Staff Organizations at

https://inside.uthouston.edu/hoop/01/1_18.html and

The University of Texas System Rules and Regulations of the Board of Regents Series 50202 (http://www.utsystem.edu/bor/rules/50000Series/50202%202004%2012%2010%2001.pdf) for detailed information.

Please complete this application form and present it with a copy of the organization’s by-laws

to the Student Affairs office. Your application will be reviewed by the Associate or Assistant Dean and recommended

for approval/disapproval to the Executive Vice President for Academic Affairs. You will be notified of the outcome.

Organization Name:

Contact Person:

(A member or officer who has authority to speak on behalf of the organization.)

School:

Address:

Phone Number:

Email Address:

Purpose and Objectives: (Attach additional pages if necessary.)

Main Activities or Programs: (Attach additional pages if necessary.)

Leadership/Officers: (Note: This list must be kept current and accurate throughout the year.)

By-Laws: (Attach additional pages if necessary.)

On behalf of the members of the ___________________________________ organization,

I certify that I have read and understand the policies of The University of Texas System and

The University of Texas Health Science Center at Houston regarding registration of student

organizations and that the information provided is true and correct. The organization agrees

to comply with said policies. As a condition of being a registered organization or group, it

must submit a completed application at the beginning of each fiscal year. Failure to comply

with the policies will result in termination of the organization’s recognition as a

University of Texas Health Science Center at Houston student organization.

I further certify that the _________________________________ organization does not have

as a member any person who is either a registered student, a faculty member, or a staff

member of any other institution than The University of Texas Health Science Center at Houston.

I understand that if I, or a representative of my organization, fails or refuses to sign this

statement, or if the president determines that the statement is false, the president,

after providing notice, shall begin disciplinary proceedings.

___________________________________________________ ___________________

Organization Spokesperson Date

____________________________________ _______________________________

Office Phone Number

RECOMMENDATION: q Approval q Disapproval

___________________________________________________ ____________________

Dean Date

APPROVAL:

___________________________________________________ ____________________

Executive Vice President for Academic Affairs Date