Departing House Staff form

Returning?

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VUMC Residents and Clinical Fellows: Congratulations to all of you who are completing residency or fellowship training at VUMC this academic year and transitioning to a new professional phase in July. We welcome you into the Vanderbilt Medical Alumni Association (VMAA) as Active Members. The VMAA numbers over 22,000 Vanderbilt Med. School grads and former VUMC trainees--a very strong group of Vanderbilt physician alums that spans multiple generations, specialties, and countries. Watch for VMAA events at national specialty conferences and regional events in your area!

Whether you are leaving VUMC or staying to pursue additional training or a faculty position, please take a moment to respond to the brief Redcap Survey below--especially your permanent email address and your forwarding mailing address (home and/or business if known).

The Vanderbilt Medical Alumni Association (VMAA)

medalumni@vanderbilt.edu

(615) 322-0310

Departing Year

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First name

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Last name

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Maiden name (if applicable)

Nickname (if applicable)

Phone number (cell)

What is your spouse's name, if applicable?

Preferred NON-VANDERBILT email address for future communications (ex. G-mail)

* must provide value

Please indicate the VUMC residency/fellowship you are completing (List department/division and program, ex: Med/cardiology fellowship)

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What is your medical specialty (and sub-specialty, if applicable) ?

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Are you leaving Vanderbilt to go to a new academic institution, community practice, or other professional opportunity? (please select NO if you are remaining at Vanderbilt)

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Yes

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What type of practice will you be pursuing?

Please specify:

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Name of academic institution or practice

Start date (if applicable) (MM/DD/YYYY)

M-D-Y

End date (if applicable- i.e., end of fellowship, training, etc) (MM/DD/YYYY)

M-D-Y

Current street address

Current street address line 2 (if needed)

City

State

Zip code

The address will be current beginning:

M-D-Y

Forwarding address

Forwarding address line 2 (if needed)

City

State

Zip code

Do you have any other information that would be helpful for our database? (Ex: children's names, previous graduate/undergraduate degrees, etc)

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