Southern Illinois University School of Medicine

$SIU School of Medicine\$
	Office of Student Affairs

Student Information Update Form

In order to keep SIU School of Medicine's student records current, please complete the following information.

Class
First Name
Last Name
Street Address
City
State
Zip Code
Phone
Email

Parent Information:	Parents' names, address and phone (list both if separated/divorced). If deceased, please indicate.
First Name(s)
Last Name
Street Address
City
State
Zip Code
Phone

Deceased?

First Name(s)
Last Name
Street Address
City
State
Zip Code
Phone

Spouse's Information:	If you are married.
First Name
Last Name
Hometown
Education
Birth Date
Date of Marriage
Number of Children