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Alumni Association Form

Thank you for your willingness to help our students and to become more involved in our program.

Please be assured that we will not publish or give your information to anyone without your permission.

Areas of Interest

Please check one or more boxes below.

Contact Information

Name*

Sackler Class Of*

Title

Specialty

Hospital/University Affiliation

Email*

Telephone Number*

Address Please Provide Your Mailing Address Here

If you wish to become an advisor, mentor and/or volunteer,
please fill out the appropriate fields below.

U.S. Electives & Residency Program Advisor

Yes, I would like to advise students as they apply for
U.S. ElectivesResidency ProgramsBoth

How many students per year could you advise?

How do you wish to establish contact?
Let the student(s) contact me via email.Send me the students’ contact information and I will get in touch with them.

Medical School Mentor

Yes, I would be available to mentor a Sackler student.

How do you wish to establish contact?
Let the student(s) contact me via email.Send me the students’ contact information and I will get in touch with them.

Alumni Association Volunteer

I would be most interested in

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