Membership Application
* indicates items which are required for submission.
First Name:*
Last Name:*
Current Year in School:
Major:
Email:*
Telephone:
	Day:
	Evening:*
	Best time to call:
Address Line 1:
Address Line 2:
City:
State:
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Zipcode:
Will you be able to make a one year commitment to the Student Health Advisory Committee (SHAC) ?
	Yes
	No
Briefly describe your volunteer service goals. List any abilities or experiences you think will help you as a SHAC member.
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