Student Health Advisory Committee (SHAC) Application

Date:

Name:

Home/Dorm Phone:

Work Phone:

Address:

City:

State:

Zip:

E-mail:

Year of School:

College:

Gender:

Male
Female

Major:

Activities/Community Service, duration:

What previous experiences or ideas or qualifications will you bring to SHAC?:

What group of students will you represent on SHAC? How will you improve communication with them?:

Please explain why you are interested in serving on SHAC:

Goals for SHAC involvement:

Future Career Goals:

Resume:

No more than one side of one page

Fields marked with " * " are required.

Student Health and Education Services