RUSM Alumni Update Form

Help RUSM and the RUSM Alumni Relations department keep our records current by telling us about any updates to your name, contact or employment information. This will help ensure that you receive any relevant communications from RUSM and the RUSM Alumni Association.

RUSM Alumni Relations reserves your right to privacy. We will not release contact information to anyone without your permission.

Thank you for taking the time to stay connected with us!

Question Title

* 1. PERSONAL/CONTACT INFORMATION

First Name:

Middle Initial:

Last Name:

Last Name (if different at time of at time of graduation):

Graduation Year:

Preferred Phone Number:

Preferred Email Address:

Home Street Address 1:

Home Street Address 2:

Home City:

Home State/Province:

Home Zip Code:

Home Country:

Business Street Address 1:

Business Street Address 2:

Business City:

Business State/Province:

Business Zip Code:

Business Country:

Business Phone:

Question Title

* 2. PROFESSIONAL INFORMATION

Current Employer:

Current Title (Resident, Fellow, etc.):

Current Specialty:

Transitional Year Program:

Transitional Year Specialty:

Preliminary Year Program:

Preliminary Year Specialty:

Residency Program:

Residency Specialty:

Fellowship Program 1:

Fellowship Specialty 1:

Fellowship Program 2:

Fellowship Specialty 2:

Fellowship Program 3:

Fellowship Specialty 3:

State /Province of Licensure 1:

State/Province of Licensure 2:

State/Province of Licensure 3:

Board Certification 1:

Board Certification 2:

Board Certification 3:

Question Title

* 3. I am interested in becoming an Alumni Ambassador for the following (select all that apply):

Information Seminar/Webinar Panel

Alumni Mentor Program

On-Campus Specialty Panel

White Coat Ceremony Speaker

Commencement Speaker

Prospective Student Outreach

Clinical/Residency Representative

Conference/College Fair Speaker

Journey to Medicine Program

Match Day Event Representative

Regional Chapter Leader/Class Representative

New Student Mixer

Profile in Marketing Material

Alumni Association Council Member

New Student Orientation Ambassador

Government Relations Ambassador

Media Relations Ambassador

None at this Time