Alumni Association Member Form

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* 1. Full Name (provide us FIRST NAME and LAST NAME)

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* 2. At what email address would you like to be contacted?

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* 3. What's the best phone number to reach you at (include area code)?

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* 4. What is your current address (provide full address)?

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* 5. What year did you graduate from your program?

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* 6. What program have you completed?

CNA

MA

MiBC

MRI

DMS

LVN

PTA

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* 7. What type of participation are you interested in?

I want to be a mentor

I want to participate in the Blood Drive

I want to participate in the Cancer Walk