高雄醫學大學學生社團新任正副社長基本資料表

Kaohsiung Medical University

General Information Form for Student Club New President and New Vice-President
中文社名 英文社名 社員數
(Club (Club (Number of
Name) Name in Club
English) Member)
社長 中文姓名 英文姓名 學號
請貼照片 Name (In Name (In (Student ID
(President) Chinese) English) No.)
(Photo) 學院中文名 學院英文名
College (In College (In
Chinese) English)
系所中文名 系所英文名
Department Department (In
(In Chinese) English)
年級 Grade 年級 Grade (In
(In Chinese) English)
手機 E-mail
(Mobile)
副社長 中文姓名 英文姓名 學號
(Vice - Name (In Name (In (Student ID
President) Chinese) English) No.)
□有(Yes) 學院中文名 學院英文名
□無(No) College (In College (In
Chinese) English)
系所中文名 系所英文名
Department Department (In
(In Chinese) English)
年級 Grade 年級 Grade (In
(In Chinese) English)
手機 E-mail
(Mobile)
副社長 中文姓名 英文姓名 學號
(Vice Name (In Name (In (Student ID
President) Chinese) English) No.)
□有(Yes) 學院中文名 學院英文名
□無(No) College (In College (In
(社員數 21 Chinese) English)
人以上得 系所中文名 系所英文名
增設/Adde Department Department (In
d to a club (In Chinese) English)
 that has 年級 Grade 年級 Grade (In
more than (In Chinese) English)
21 手機 E-mail
members) (Mobile)
副社長 中文姓名 英文姓名 學號
(Vice - Name (In Name (In (Student ID
President) Chinese) English) No.)
□有(Yes) 學院中文名 學院英文名
□無(No) College (In College (In
(社員數 41 Chinese) English)
人以上得 系所中文名 系所英文名
增設/Adde Department Department (In
d to a club (In Chinese) English)
that has 年級 Grade 年級 Grade (In
more than (In Chinese) English)
41 手機 E-mail
members) (Mobile)
新任社長(New President Signature)：
新任副社長(New Vice-President Signature)：
輔導老師(Club Guidance Teacher Signature)：
備註/ Note：
1：存檔後請印出簽章，於規定日期前繳至課外活動組，作為核發正副社長證書之依據，填錯、逾時
不補發證書。
Please save and print this form, then submit it to Division of Extracurricular Activities with
SIGNATURES before due date. Certificates of president and vice-president will be issued based
on this form. No reissue will be made if the form is filled out incorrectly or submitted after due
date.
2：Applicants are agree by consent to allow personal information provided above to be
utilize by Kaohsiung Medical University for student club consulting purposes and
related affiliates. 填寫人同意校方基於輔導社團之目的，將個資運用於社團輔導等相關業務。
3：Participants to run for Club President position already notify his/her legal
guardian(s) with his/her legal guardian(s)’ approvalStudent Sign:
擔任社團社長職務已告知法定代理人並獲得法定代理人同意，學生簽名：╴╴╴╴╴

保存期限：三年/ Valid for 3 years. CS502-A603-010810