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Reunion Weekend 2013 Registration
For Classes 1978, 1983, 1988, 1993 and 2003

This form is for registering for any and all events EXCEPT for the Saturday evening dinner.


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 an 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 21
  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 Hilton Hotel between 6:10 - 7 p.m. and return at 8:30 & 9:00 p.m.

  Will you use the shuttle service? * Yes No
  If so, how many passengers?
 
Saturday, June 22
  Campus Tour
  Will you be attending the walking tour of campus conducted by Dr. J. Kevin Dorsey, Dean and Provost.
  Class of 1978 Picnic
  A family picnic will be hosted by Jane and Steve Arbuthnot. Details and directions will be provided via the class listserv.
 
  Number Attending Vegetarian Meals Requested  
Alumni, Adult Spouse/Guest, Children 13 and older
Children-Ages 6-12
Children-Ages 5 and younger
 
  Class of 1983 Picnic
  A family picnic will be hosted by Ron and Therese Romanelli. Details and directions will be provided via the class listserv.
 
  Number Attending Vegetarian Meals Requested  
Alumni, Adult Spouse/Guest, Children 13 and older
Children-Ages 6-12
Children-Ages 5 and younger
   
  Class of 1988 Picnic
  A family picnic will be hosted by Andy and Carol Varney. Details and directions will be provided via the class listserv.
 
  Number Attending Vegetarian Meals Requested  
Alumni, Adult Spouse/Guest, Children 13 and older
Children-Ages 6-12
Children-Ages 5 and younger
   
   

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:

Biosketch 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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