Indiana University
IUSM IU
IU School of Medicine

Indiana University Medical Alumni-Student Connection Volunteer Form

Items in bold are required.

First Name:
Last Name:
Medical Specialty:
Home Address:
Home Phone:
Office Phone:
E-mail Address: *
I am currently in a residency program at:
Spouse Name:
Children and Ages:
Special Interests:
Hometown:
Undergraduate Degree:
Additional information you might wish to share:
I am willing to provide the following services:
(check all that apply)
Phone conversation
E-mail communication (*must provide E-mail address)
Job Shadow
Personal Meeting
Host a 4th year medical student conducting residency search in my home
Resume Review