Information Form for SMD'24 Students – UVA Medical Alumni Association

Information Form for SMD’24 Students

The information gathered from this form will be used to help the UVA Medical Alumni Association plan the White Coat Ceremony and Family Day, as well as to keep your family members updated on School of Medicine news. ** Please complete form by September 4, 2020. Thank you. **

STUDENT INFORMATION
Admitted Student's Full Name*
Salutation*
First Name*
Last Name*
Suffix (Jr., PhD, MSPH, etc.)
Phonetic Pronunciation for First Name
If your name could be pronounced more than one way, please complete this section with your preferred pronunciation.
Phonetic Pronunciation for Last Name
If your name could be pronounced more than one way, please complete this section with your preferred pronunciation.
Preferred Email Address*
UVA INFORMATION
Do you have any immediate family members (ONLY parents, spouses or siblings) who graduated from the UVA School of Medicine, did their residency at UVA, or are currently serving on the SOM faculty?*
If yes, please provide name of family member and relationship
FAMILY INFORMATION
Please enter contact information for parents, guardians and spouses only
Family Member 1
Relationship to student*
Other:
Prefix*
First and Last Name*
Please include any suffixes (Jr., III, MD, etc.)
Email*
Street Address*
City*
State*
Zipcode*
Country
Family Member 2
Relationship to student
Other:
Prefix
First and Last Name
Please include any suffixes (Jr., III, MD, etc.)
Email
Is the physical address the same as Family Member 1?
Street Address
City
State
Zipcode
Country
Family Member 3
Relationship to student
Other:
Prefix
Other:
First and Last Name
Please include any suffixes (Jr., III, MD, etc.)
Email
Is the physical address the same as Family Member 1?
Street Address
City
State
Zipcode
Country
Family Member 4
Relationship to student
Other:
Prefix
Other:
First and Last Name
Please include any suffixes (Jr., III, MD, etc.)
Email
Is the physical address the same as Family Member 1?
Street Address
City
State
Zipcode
Country

Resources For...

Students

Alumni

Housestaff

Faculty

Information Form for SMD’24 Students

Information Form for SMD’24 Students

STUDENT INFORMATION

UVA INFORMATION

FAMILY INFORMATION

Family Member 1

Family Member 2

Family Member 3

Family Member 4