Leader's Name *

First Name

Last Name

Leader's Phone Number *

(###)

###

####

Target Group *

Who will your group mainly be made of

Students

Staff/ Faculty

Both

Group Gender

Males only

Females only

Co-Ed

Meeting Address

Please fill out where your COLLECTIVE group will regularly hold their meetings.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country