Student/Alumni Dinner Host Form | SIU School of Medicine

Thank you for your interest in the Student/Alumni dinners! To sign up to be a dinner host for the medical students, please complete the form below by February 3, 2023.

Should you have any questions, please connect with Cassie Mattson at cmattson53@siumed.edu.

Name

Class Year

Address

City

Preferred Phone

Please indicate if the phone number is a work phone, cellphone, or home phone.

Email address

Please select how you would like to host the students for dinner:

I am interested in hosting students at my home

I am interested in hosting students at a restaurant

If you answered yes to hosting at a restaurant, please provide the name, address, phone (if possible) of restaurant below:

Number of students I am willing to host:

Can a student bring their spouse or significant other?

Yes

Date I would like to host:

Monday, March 6 (Carbondale)

Tuesday, March 7 (Carbondale)

Wednesday, March 8 (Springfield)

Thursday, March 9 (Springfield)

Time I would like to host:

Specific details or parking instructions for students: