University of Iowa Carver College of Medicine

Class Reunion Memory Book Questionnaire

The information below will be published in your class reunion Memory Book. Please send us this information via the Internet by using this web form. Your information will be included whether or not you plan to attend the reunion, so please, send your information so we can update your classmates! For questions contact us at (319) 335-8886 or medicine-alumni@uiowa.edu. Also please send photos for the Memory Book to medicine-alumni@uiowa.edu or via mail with your registration. We look forward to seeing you in June.

Return Deadline:

May 13, 2011 for MD Classes of 1936, 1946, 1951, 1951, 1956, 1961, 1966 and 1971

MD graduation year

Do you plan to attend the reunion?

Yes No

Title:
First Name:
Middle Initial:
Last Name:
Maiden Name:
Pref. Name or Nickname:
E-mail Address:

Home Address Line 1:

Home Address Line 2:
City:
State:
Zip:
Home Phone:

Office Address Line 1:

Office Address Line 2:
City:
State:
Zip:
Office Phone:

If you have a seasonal or additional address, please indicate below:

Additional Address Line 1:

Additional Address Line 2:
City:
State:
Zip:
Dates at Address:
Phone at Address:

Family

Marital Status:
Spouse Title:
Spouse/Partner First Name:
Spouse/Partner Middle Initial:
Spouse/Partner Last Name:
Year Married:
Spouse/Partner Occupation:
Spouse/Partner Employer:
Is Spouse/Partner a UI graduate? Year?

Children
Title	First Name	MI	Last Name	Birth Date	Occupation

Indicate additional children below: Something my classmates do not know about me is:

Medical School Memories

Favorite memory of your time at the UI College of Medicine: Most memorable professor:

Why? What people or places do you remember the most about your days in Iowa City:

Medical Career

Internship

City:
State:
Years:
Residency City:
State:
Years:
Fellowship/Other City:
State:
Years:
Specialty:
Subspecialty:

How has the UI College of Medicine contributed to your life/work: Where have you been employed since your time here at the UI College of Medicine:

Are you retired?

Yes No

If so, what year?

Medicine Magazine is the magazine for the University of Iowa Carver College of Medicine Alumni that provides alumni and friends with information on current events involving the College and its graduates. Some of the following responses may be reprinted in the Medicine Magazine Alumni Notes section.

What are your current activities and interests (hobbies, travels, etc.): what awards/honors have you received during your medical career: Tell us about your service to your alma mater: How are you involved with your community: What have been some of your most rewarding career highlights: Other Information:

Contact

Medicine Alumni Society
medicine-alumni@uiowa.edu
Phone: 319-335-8886
Toll Free: 877-MEDIOWA
Fax: 319-384-1746