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Reunion Weekend 2014 Registration
For Classes 1979, 1989, 1994, 1999 and 2004

If you are attending only complimentary events (Friday evening reception, campus tour, Class of 1989 picnic - payment required at picnic), please use this link to Register Proceed to Friday Registration

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

Birth Date

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 27
  Reception
  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.
Shuttles will leave the Hilton between 6:10 - 7:00 pm from the hotel´s main entrance on Adams Street. Return shuttles will operate from Island Bay Yacht Club at 9:00 pm.

  Will you use the shuttle service? * Yes No (Complimentary)
  If so, how many passengers?
 
Saturday, June 28
  Campus Tour
  (Complimentary)
  Will you be attending the walking tour of campus conducted by Dr. J. Kevin Dorsey, Dean and Provost.
 
Class of 1979 Picnic
  Hosted by David and Ingrid Alexander, Springfield
 
  Number Attending Vegetarian Meals Requested
Alumni, Adult Spouse/Guest,
Children 13 and older $12/person
Children - Ages 6-12 $6/person
Children - Ages 5 and younger Free
   
  Class of 1989 Picnic
  (Alumni and guests will order from menu and pay at event)
  Lunch in the clubhouse at Longbridge Golf Course, Springfield, Il.
 
  Number Attending
Alumni, Adult Spouse/Guest, Children 13 and older
Children - Ages 6-12
Children - Ages 5 and younger
   
  Class of 1999 Picnic
  Picnic at Erin’s Pavilion
 
  Number Attending Vegetarian Meals Requested
Alumni, Adult Spouse/Guest $12/person
Children - Ages 6-12 $6/person
Children - Ages 5 and younger Free
   
 

Class of 2004 Picnic

  Picnic at Washington Park
 
  Number Attending Vegetarian Meals Requested
Alumni, Adult Spouse/Guest, Children 13 and older $12/person
Children - Ages 6-12 $6/person
Children - Ages 5 and younger Free
   
  Saturday Evening Event - $50 per person
 
  Attending    
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 217-545-5770.
Questions

If you have any questions please enter here:

Memory Book Info
Please share your current practice / professional information:

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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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Don't forget to send us your alumni update
Don't forget to reserve a hotel room