Southern Illinois University School of Medicine Office of Alumni Affairs


Alumni Profile Form

Help us keep your record current by updating the form below. The information is used only by SIU and is not made available to outside individuals or organizations. Information about your specialty and practice location are important to the overall mission of the School of Medicine. We welcome receiving a copy of your curriculum vitae by U.S. mail or attached to an email sent to


Alumni Personal Information
* Required
Graduation Year*    
First Name*  Last Name*  
Maiden Name

Name at Graduation
Home Address* City*
State / Province Postal Code
Home Phone*
area code, prefix, number
Your email address will only be used by Alumni Affairs to contact you
Cell Phone
area code, prefix, number
Spouse / Partner
First Name Last Name
Is this person your spouse or partner?
Is your Spouse / Partner an SIU SOM Alumni?  
Please list children's names, gender and birthdate (including year):
Career Information
Professional Status
If "other" please list:
Organization Position Title
Work Address
City State Postal Code
Business Phone

area code, prefix, number

area code, prefix, number
Business Email
Please share your career honors, awards, accomplishments & highlights.
Participation in the HOSTS Program
We hope that you are willing to HOST a student when one is in your area for residency interviews.
Learn more about the SIU SOM HOSTS Program Learn More
Alumni responses to the questions below will help the Office of Alumni Affairs make optimal matches with 4th year medical student travelers. Interview activity occurs between the months of September and January. The Office of Alumni Affairs will contact you with requests for accommodations.
Yes, I would like to Host a student
Check this box if you DO NOT wish to participate in the HOSTS Program.
Not at this time, but please contact me to host after this date -
Please describe the overnight accommodations in the text box below (Example: private spare bedroom, bedroom shared w/child, family room sofa, etc.)
Please indicate, if you have indoor pets, the number of pets (for allergy considerations).
Dog(s)   Cat(s) Other
Please indicate species and number
Do any of your family members smoke?
Share Your News / Interests
We welcome news about your personal or professional life that you would like to share with classmates and other readers of Aspects.

Activities, travels, family changes, hobbies, new interests, or other information you would like to share with others.

(Maximum characters: 3500)
Characters left.
If you would like to accompany your news with a photo(s) please follow the instructions on the response page that appears after completing this form.
Thank You!
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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