Department of Exercise & Sport Sciences Alumni Ithaca College

Title: Dr. Mr. Ms. Mrs.
First Name: Middle Initial:  ( Maiden Name:  )
Last Name: 
Graduated IC: 

Home address:
(line 1): 
(line 2): 
City: State: Zip: 
Telephone number (xxx-xxx-xxxx): 
E-mail: 

Received Ph.D.:  Yes  No  Pursuing
Received MS/MA:  Yes  No  Pursuing
Received Professional/Allied Health degree:  Yes  No Pursuing (If Yes or Pursuing, what type of degree: )


Post Graduate Institutions:
Institution 1:  Degree:  Year Earned: 
Institution 2:  Degree:  Year Earned: 
Institution 3:  Degree:  Year Earned: 

Work title: 
Employer: 
Work address:
(line 1): 
(line 2): 
City: State: Zip: 
Telephone number (xxx-xxx-xxxx): 
E-mail: 

Would you be able/interested to return to IC to talk to students? Yes No

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