SGB New Club Proposal

Name of Organization *

Club Website

Is this Organization an Interest Group**? *

Yes No

Faculty Mentor (Required for Interest Groups) *

Faculty Mentor Email Address (Required for Interest Groups) *

* An Interest Group is defined as a group/club of students who have a interest in a specific medical or scientific area (for instance: radiology, oncology, neuroscience, immunology, etc.). These groups must have a faculty advisor.

Is your club or interest group affiliated with a larger/national organization? *

Yes No

Name of affiliated organization *

Website of affiliated organization *

Is this organization providing funding to your group? *

Yes No

Board Members (please list all members) *

	Name	Email	Title
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Club Mission Statement (to be displayed on OSA website) *

OSA Club Website: http://www.einstein.yu.edu/education/student-affairs/student-activities/involvement/clubs/

Contact Email for OSA Website *

Proposed Events for Current Academic Year *

	Event	Event description	Estimated cost for event
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Any Additional Comments?

E-mail address that all SGB correspondences should be addressed to (including activation of your budget, if your club is approved) *

Einstein E-mail address of club leader submitting proposal *

example@einsteinmed.org

If your proposed Club/Interest Group is approved you agree to comply to all SGB policies. Please note that the SGB will receive your submission after hitting submit, even if you do not see a confirmation screen.

Einstein SGB New Club/Interest Group Proposal Form