Student Club Petition

Use this form to submit your request for establishing or renewing a student club!

Basic Information

Is this a renewal?*

Yes, we already existed

No, we are establishing a new club

Region:*

Select

Name of EMBS Club:*

Academic Institution (University):*

Street Address:*

City:

Country:

Select

Name of Attention:

Chair Email Address:*

Club Website (if available):*

Student Club Officers

We, the officers of the above named IEEE EMBS Student Club, hereby petition for approval to form an IEEE EMBS Student Club. At least one member of the Student Club, or the advisor, is an IEEE EMBS member.

Chair Name:

Chair IEEE Number:

Vice-Chair Name:

Vice-Chair IEEE Number:

Club Secretary:

Club Secretary IEEE Number:

Club Treasurer IEEE Number:

Student Club Faculty Advisor

Faculty Advisor Name:

Faculty Advisor Email*

Faculty Advisor's IEEE Number

Academic Institution or University:

Department:

Agreements

***

I understand that the faculty advisor must send an email confirming that they are aware of their position to the EMBS Executive Office (Kelly Phillips Shields, k.phillipsshields@ieee.org) in order for my petition to be processed.

****

I hereby confirm that prior to submitting this form, myself or the student club chair has already submitted a list of our club membership (including, at a minimum, member names, member email addresses, and date member joined the club) to the EMBS Executive Office (Kelly Phillips Shield, k.phillipsshields@ieee.org) in order for this petition to be processed.

File Upload

Upload associated files as necessary.

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.