Ithaca College Health Professions Alumni Advisory Council Network Registration Form

Title:  Dr.  Mr. Ms. Mrs.
Name:
Class: 
Profession: 

Home address: (KEEP TO 2 LINES)

    City, State, Zip: 
    Telephone number (xxx-xxx-xxxx): 
    E-mail: 

Work title: 
 Organization: 

Work Address: (KEEP TO 2 LINES)

    City, State, Zip: 
    Telephone number: 
    E-mail: 

Preferred method to reach you and when: 
Profession school attended: 
Residency (if applicable): 
Current specialty (if applicable): 
Briefly describe your work:

Please indicate which of the following you would be willing to participate in:

I want to be in the network directory
I welcome direct contact from students
I am willing to let students shadow me at work
I can provide clerkship for students
I can provide research opportunities for students
I am willing to visit campus and speak to students about my specialty or other experiences
Other: 

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Page maintained and updated by Jean Hardwick and Nancy Pierce.
Last udpated 8/06