MISSION STATEMENT

CLUB AND ORGANIZATIONAL

APPLICATION FORM

Student Organization Registration Form 2004-2005

Office of Student Union and Involvement - Longwood University

Check one: ___New Organization ___Re-Registering ___Name Change (Previous Name____________)

Name of Organization:__________________________________________________________________

Organizations names may use “Longwood University” to identify location only (e.g. Student Club at Longwood not Longwood Student Club.)

P.O. Box of Organization:__________________________Phone Number:________________________

Organization’s Email:_________________________Month of Elections:_________________________

Number of Members:_________Regular Meeting day and time:________________________________

President’s Name:_______________________________________Email:________________________

Local Address:________________________________________Phone Number:_________________

Vice President’s Name:__________________________________Email:________________________

Local Address:________________________________________Phone Number:_________________

Secretary’s Name:______________________________________Email:________________________

Local Address:_________________________________________Phone Number:________________

Treasurer’s Name:______________________________________Email:_______________________

Local Address:_________________________________________Phone Number:________________

Volunteer/Service/Learning Coordinator____________________________________________

Email:_______________________Local Address:______________________________________

Phone Number:__________________________________________________________________

Other Officer__________________________________________Email:________________________

Local Address:_________________________________________Phone Number:________________

As President of this organization, I assume responsibility to ensure that all members are aware of and abide by regulation pertaining to student organizations and to conduct our affairs in a manner to further the educational mission of the college.

Signature of President:_________________________________________________Date:___________

STUDENT ORGANIZATION ADVISOR CONFIRMATION

*The Advisor must be a faculty member, administrator, or staff member of Longwood University*

Having met with the leadership of the above organization, and having become familiar with its purpose, I am willing to serve as advisor for this year, and am aware of an advisor’s responsibilities, which include:

1. Promoting student/staff/faculty cooperation.

2. Working with the Office of Student Union & Involvement to affect constructive programming and support for the organization.

3. Promoting student awareness of and adherence to Longwood and other University policies and procedures for campus clubs and organizations.

4. Reporting to the Office of Student Union & Involvement any violations of University policies & procedures, including any unsafe practices of this organization.

5. All club sports must have the signature of the Director of Campus Rec.

Advisor’s Name:______________________________________Dept/Office:_____________________

Campus Address:______________________________________Campus Phone:__________________

Email:_______________________________________________

Signature of Advisor:__________________________________________________Date:____________

Signature of Campus Rec Director___________________________________________Date:____________

(If Club Sports)

Please check one category below that most closely defines your organization. Your organization will be listed under this heading on our website and in publications designed to promote student organizations.

___Academic Departmental ___Residence Hall

___Advocacy ___Service

___Campus Media ___Social Greek Organization

___Club Sports/Recreation ___Special Interest

(If Club Sports/Recreation – your organization ___Spiritual/Religious

must meet with the Campus Rec Director) ___Student Government

___Honorary

STATEMENT OF PURPOSE: Briefly describe the purpose of your organization. Be as precise as possible since this statement will be listed on our website and in publications.

CONSTITUTION INFORMATION

Check Appropriate Response:

___ I certify that our constitution and bylaws have not changed.
___ Our constitution and/or bylaws have changed from last year, attached is an updated copy.
___ As a new organization, attached is a copy of our constitution and bylaws.

Date of last revision of constitution and/or bylaws (if less than one year please attach)

____________________________________________________________________

By completing and submitting this Registered Student Organization Application:

I certify that the above information is accurate, and I acknowledge my responsibility to keep this record correct by informing the Office of Student Union and Involvement of any changes in the information and/or in our constitution and bylaws.
I certify that this organization does not discriminate on the basis of race, national origin, color, religion, gender, age, veteran status, sexual orientation, and/or ability status in any of its programs, activities, services, benefits, or membership practices. Under Title IX of the U.S. Education Act Amendment of 1972, certain exemptions may be granted for groups such as intercollegiate and intramural athletics, social fraternities and sororities, girl scouts, and boy scouts.
I understand that information listed on this application will be made available to the public.
I understand that our organization must re-register with the Office of Student Union and Involvement at the beginning of each semester of the academic year and will submit changes in our officers and/or advisor as they occur throughout the year.

Signature of President:___________________________________________Date:__________________

Signature of Advisor:____________________________________________Date:__________________

Please return to Lankford Student Union Room 201