Alumni Memory Book | SIU School of Medicine

Thank you for taking the time to tell us about yourself! Information submitted on this form will be compiled into a class-specific document for your class reunion. The document will be available via PDF and loaded onto a flash drive that will be given to you once you arrive and register. Additionally, we will have paper copies of the booklet available for those who request them through this form.

Alumni Personal Information

First Name

Last Name

Name at time of graduation

Mailing Address Line 1

Mailing Address Line 2

City

State/Province

Zip

Country

Preferred Email

Preferred Phone

Please indicate if the phone number is a work phone, cell phone or home phone.

Class Year

Specialty

Please attach your SIU SOM graduation photo, current headshot and any other photos from your time at SIU SOM or from your years in practice.

Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: gif, jpg, jpeg, png.

Spouse/partner

First Name spouse/partner

Last Name spouse/partner

Is this person your spouse or partner?

spouse

partner

Is this person an SIU SOM alumnus/a?

If so, what class?

Child(ren)

Please list child(ren)"s name(s) (first and last name) and birth date(s)

News/Interests

Publish current practice information (if new) in Aspects magazine?

yes

Publish career summary (if it contains new info) in Aspects magazine?

yes

My most memorable experience from medical school (for memory book only):

Most interesting/remarkable thing(s) I've done since medical school (for memory book only):

Top reason(s) I'm glad I graduated from SIU SOM (for memory book only):

A copy of the memory book will be available to you via PDF and given to you on a flash drive at Reunion. Check yes, if you would still like a paper copy.

Yes