Reunion Survey

We would love to hear from everyone from the Reunion Weekend classes. Please submit this survey even if you are unable to attend the Reunion. We also encourage you to submit a photo of yourself by attaching it to an e-mail and sending it to Nicki Crellin, Associate Director for Advancement, at Photos will be included in the Reunion Memory Book.

Graduation year:

Do you plan to attend Reunion?

Yes No


Home address:
Home phone:


Do you want to be registered for the online BSOM E-mail Directory:

Yes No

Spouse's name
and occupation:

names and ages:

Employment history:

People or places
you remember:

Favorite professor:

Advice to medical
students today:

Medical school's contribution to
your life and/or work:

Service to your
alma mater:

Current activities
and interests:

Community service involvement:

What is your greatest accomplishment since graduating?:

Fun fact about yourself:


Thank you for your time, and we hope to see you at reunion!
You may also fill out this form, print it and send or fax a copy to:
Office of Advancement
Boonshoft School of Medicine
3640 Colonel Glenn Highway
Dayton, OH 45435

Fax: (937) 245-7949