Southern Illinois University School of Medicine Office of Alumni Affairs

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Reunion Registration

If you aren't attending any events that require payment, please don't use this registration

Use this link if you don't have anything to pay for

 

Registration implies the consent of the registrant and adult guest(s) for the use of photographic images on the School of Medicine alumni web page and in Aspects magazine.

Alumni Information
* Required Field      
First Name *
(for badge)
Last Name *
Maiden Name
(or name at time of graduation)
   
Class Year* Specialty
Mailing Address * City *
State / Province * Postal Code *
Home Phone*
area code, prefix, number
Preferred Email *
Business Phone
area code, prefix, number
Secondary Email
Cell Phone
area code, prefix, number
   
Spouse / Guest
Check one:  Spouse Guest    
Is your spouse/guest a SIU SOM Alumni?



   If so, what year?
 
First Name
(for badge)
Last Name
(for badge)
Children
Are your children attending with you?
Yes No
 
If so, please tell us their name, birth dates (including years) and gender.

 

Children's Names

Date of Birth

Gender

 
 
 
 
 
 
Special Needs / Vegetarian Requests
Pursuant to the Americans with Disabilities Act, please advise if you or your guest(s) require special assistance to fully participate in reunion activities. Please communicate any food allergies, request vegetarian selections for any of the reunion events, or indicate special needs in the text box below. Please specify which guest has special needs.
 
Events
Friday, June 26
  Reception - Complimentary
  How many will attend?
  Adults & children 13 and up  
  Children 6-12?

  Children 0-5?  
  Of the children listed above, how many would like to:
  Play Games Children must be accompanied by an adult.
  Swim Children must be accompanied by an adult.
  Complimentary shuttle to / from Island Bay Yacht Club will be provided.
Shuttle will depart President Abraham Lincoln Springfield Double Tree Hotel between 6:10 - 7 p.m. and return at 9:00 & 9:30 p.m.

  Will you use the shuttle service? * Yes No
  If so, how many passengers?
 
Saturday, June 27
  Campus Tour
  Will you be attending the walking tour of campus conducted by Dr. J. Kevin Dorsey, Dean and Provost, Dr. Chris McDowell '05 and Student Ambassadors?
  Class of 1980 Picnic
  Picnic hosted at Jim and Susan Stegeman’s home. Details and directions will be provided via the class listserv.
 
  Number Attending Vegetarian Meals Requested  
Alumni, Spouse/Guest
   
  Class of 1984/1985 Picnic
  Informal gathering at Walnut Street Winery in Rochester.
Alumni and guest will order from menu and pay at event
 
  Number Attending    
Alumni, Spouse/Guest
   
  Class of 1990 Picnic
  Informal gathering at Obed & Isaacs Microbrewery & Eatery
Alumni and guest will order from menu and pay at event.
 
  Number Attending    
Alumni, Adult Spouse/Guest, Children 13 and older
Children-Ages 6-12
Children-Ages 5 and younger
   
  Class of 1995 Picnic
  Picnic hosted at Jim and Lisa Thiele’s home. Food and drinks provided.
 
  Number Attending Vegetarian Meals Requested  
Alumni, Adult Spouse/Guest, Children 13 and older
Children-Ages 6-12
Children-Ages 5 and younger
  Class of 2000 Picnic
  Picnic at Careyana & Andrew Brenham’s home.
 
  Number Attending Vegetarian Meals Requested  
Alumni, Adult Spouse/Guest, Children 13 and older ($12)
Children-Ages 6-12 ($6)
Children-Ages 5 and younger (free)
  Class of 2005 Picnic
  Picnic at Washington Park Pavilion.
 
  Number Attending Vegetarian Meals Requested  
Alumni, Adult Spouse/Guest, Children 13 and older ($12)
Children-Ages 6-12 ($6)
Children-Ages 5 and younger (free)
  Saturday Evening Event - $50 per person
  Reunion Celebration Appetizers & Food Stations
 
  Attending Vegetarian  
Alumni
Guest

If you wish to bring additional adult guests, please contact Sheryl Lloyd or Cris Milliken at slloyd@siumed.edu or cmilliken@siumed.edu or call 217-545-7800.
Questions

If you have any questions please enter here:

Memory Book Info
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Career Summary (include any leadership positions you hold or have held):

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Most memorable medical school experience:

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Most interesting/daring thing I’ve done since medical school:

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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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