Office of Public Affairs

Public Information Program - Information Request
Memory and Aging Network
Center for Alzheimer Disease and Related Disorders
SIU School of Medicine

If you have any questions, please contact the Office of Public Affairs at SIU School of Medicine,
217-545-2155 weekdays or email publicaffairs@siumed.edu.

Please use tab key to move between the fields.

Network/program provider information (Printable PDF form)
Network provider
Contact name
Street address
City		Zip:
E-mail
Work Phone		Fax:
Web site
Contact for media questions (if different)		Phone:

Public education program information
Program name
Date		Time (Start/End)
Location	(Please include location name, address and room number, if applicable)
Speaker(s)	(Please include the speaker's title, organization and the title of the talk.)
Program description:	(Please explain if this is one presentation or part of a multi-talk program.)
Other sponsor(s)
Audiences for program:
Continuing education credit hours: Accrediting agency:
Any additional media besides those listed in your network provider list:

Is registration required (Y/N) Reg fee: $ Reg deadline:

Preferred method of reg: Parking (Y/N) Food & Drink (Y/N)

Enter the following in this text box: 12:34