Stay Connected-Alumni Information Form

First Name*

Last Name*

E-mail address

please enter an email address. If you do not have an email address, please leave this field blank.

Phone Number*

Street Address*

City*

State*

Zipcode*

Please indicate what degree you earned at UND (MD, MPH, PT, etc)*

Please indicate what degree you earned at UND (MD, MPH, PT, etc)

What year did you graduate?*

What years did you participate in INMED?*

please tell us what years you participated in INMED

Please tell us where you are currently employed, and your title

Please indicate your current place of employment and title

What's new with you?

Share any personal or professional highlights you'd like

Do you now or have you worked in an IHS facility? If yes, where?

Please tell us which INMED programs you participated in

Summer Institute? Degree Program? Med Prep?

What else do you want to tell us about?

Please indicate whether or not you would be interested in submitting a written or oral history as part of INMED's 50th anniversary celebration and kept as part of a digital archive. If you indicate yes, someone from INMED will follow up with you.

Yes
No

Are you interested in participating in the planning of the 50th anniversary celebration?

Yes
No

Are you interested in participating in the planning of the 50th anniversary celebration?

May we use and share your story?

Yes
No, please just update my records

By checking the "yes" box above, you are granting INMED permission to use and share your stories for recruitment and promotional purposes.

Stay Connected-Alumni Information Form

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