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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)
Characters left.
Most interesting/daring thing I've done since medical school:
(Maximum characters: 3500)
Characters left.
Thank You!