A.T. Still University

Class Newsletter Questionnaire


ATSU-KCOM is publishing a newsletter for members of the anniversary classes of 1959 and 1984.  The newsletter will provide class members with a great opportunity to connect with each other.   To participate, these class members can complete and submit this questionnaire online by July 25 or print, complete, and mail by July 25 to:

Janet M. Bunch
Director of Student & Alumni Projects
A.T. Still University
800 West Jefferson Street
Kirksville, MO 63501

A copy of the newsletter will be sent to members of the classes prior to reunion events in Kirksville
October 15-16, 2009.

Please use the tab key or move the mouse to navigate through the survey.
Using the enter key will submit the form "as is" to ATSU-KCOM.

Grad Year:
First Name:
Middle Name:
Last Name:
Home Address:
Home City:
Home State:
Home Zip:
Home Phone:
Home Fax:
Home Email:
Home Web Address:
Office Name:
Office Address:
Office City:
Office State:
Office Zip:
Office Phone:
Office Fax:
Office Email:
Office Web Address:
Hospital Affiliation:
Spouse's Name:
Spouse's Occupation:
Children's Names:

News of Interest:

Professional Affiliations (i.e., AOA, ACOFP, etc.):

Personal, Hobbies, Vacation Update:

What people or places do you remember most about your days at KCOM?

What else would you like to share with your classmates?

Information for Office Use Only (will not appear in the Newsletter)

Do you have children that are graduates of or are currently attending an ATSU college/school (KCOM, School of Health Management, Arizona School of Health Sciences, Arizona School of Dentistry & Oral Health, School of Osteopathic Medicine in Arizona)?
Yes  No

If yes, please list their name, college/school attended, and year graduated/anticipated year of graduation:

Do you have a child that may be applying to an ATSU college/school within the next five years?
Yes  No

If yes, please provide their name and the college they are or will be attending.

Where do you want mail sent?

Where do you want email sent?

Do you plan to attend your class reunion events in Kirksville October 15-16, 2009?
Yes  No Uncertain

Are you mailing a photo to appear in the Class Newsletter?
Yes  No

If so, would you like it returned?
Yes  No

Please remember to complete and submit the form by July 25.  If you have any questions or comments, please call 660.626.2067 or email jbunch@atsu.edu.

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