* Required

Name (include maiden or birth name):

Preferred first name:

Birth date:

Preferred e-mail address:

Address 1

Address 2

City

State

Zip

Country

Home phone:

Cell phone:

Name of spouse/partner:

Your Employer:

Current job title:

Business address:

Business phone:

Please list colleges and/or universities you have attended and degree(s) obtained:

Do you plan on attending your reunion during Alumni Weekend, Friday, May 2 - Sunday, May 4?

Yes  No 

Would you consider working with classmates on your reunion planning committee?

Yes  No 

If you have children, please list their name and ages below:

Class note for the Alumni Journal:

Please send a confirmation email to the address below: