Southern Illinois University School of Medicine Office of Alumni Affairs


Alumni Memory Book

Thank you for taking the time to tell us about yourself. Information contained on this page will be compiled into a class specific booklet for the class reunion. The booklet will be available in the secure area of the web site, available only to alumni.

Alumni Personal Information
* Required
First Name* Last Name*
Maiden Name
(Or name at time of graduation)
Mailing Address * City*
State / Province* Postal Code*
Home Phone*
area code, prefix, number
Preferred Email* Email address will only be used by Alumni Affairs to contact you.
Business Phone
area code, prefix, number
Secondary Email
SIU SOM Alumni, Class of    
Spouse / Partner
First Name Last Name
Is this person your spouse or partner?
Is your Spouse / Partner a SIU SOM Alumni? If so, what class?
Please list children's names and birth dates (including year):
News / Interests
Please share your current practice information.
(Maximum characters: 3500)
Characters left.
Please share your career Summary
(include any leadership positions you hold or have held).

(Maximum characters: 3500)
Characters left.
Memorable moments and activities in medical school:
(Maximum characters: 3500)
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Most interesting/daring thing I've done since medical school:
(Maximum characters: 3500)
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Thank You!
Phone 217-545-7800
P.O. Box 19650
Springfield, IL 62794-9650
The mission of Southern Illinois University School of Medicine is to assist the people of central and southern Illinois in meeting their health care needs through education, patient care, research and service to the community.


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