Old Dominion University
Student Health Advisory Committee (SHAC)
Member Application
Name ______________________________ UIN ____________________
Date of Application __________________ GPA __________
Email Address ______________________
Local Address_______________________
Home Address____________________________________________
________________________________________________________
Contact Phone #1 ___________________ Contact Phone #2 ___________________
Major _____________________________
Expected Graduation Date_____________
List honors or awards:
Extra curricular activities:
Why are you interested in joining (SHAC)?
What could you contribute to SHAC?
What are some of your career goals?
Additional information about yourself that you would like us to know.
How did you find out about SHAC?
Are you interested in becoming a peer educator? Yes/no
