REGISTRATION AS A

SEVENTH-DAY ADVENTIST HEALTH PROFESSIONAL

Dear Fellow Adventist Medical Professional,

This is an online questionnaire patterned somewhat after the items found in the Loma Linda University School of Medicine Alumni Association Directory but also included are several items about your interests and abilities that would make the database valuable for both Adventist medical fellowship and for planning medically related Church activities. It's certainly is not intended to infringe on your right to privacy and no item is a “required item” so please give all the information that you are comfortable sharing. The directory and database are joint projects of the Adventist International Medical Society in cooperation with the Loma Linda Branch Office of the General Conference of Seventh-day Adventists. It is of course impossible to guarantee who will look at a directory but the information will be shared only with fellow Seventh-day Adventist Health Professionals and health-related entities of the Seventh-day Adventist Church. Thank you very much for your effort and cooperation.

Send your response to:

Adventist International Medical Society (AIMS)

11245 Anderson Street, Suite 200

Loma Linda, CA 92354

Or via email to: AIMS Webmaster

Adventist International Medical Society (AIMS) is offering a current year dues free membership to new members.

Would you like to join? YES________ NO ____________

If no, please register as an SDA healthcare worker anyway.

Registration Form

PROFESSION____________________________________

TITLE___________

LAST NAME _____________________________________

FIRST NAME_____________________________________

MIDDLE NAME ___________________________________

NAME OF SPOUSE________________________________

EMAIL___________________________________________________________

HOME ADDRESS Line1____________________________________________________

HOME ADDRESS Line 2____________________________________________________

HOME CITY___________________________________________

HOME STATE or PROVINCE___________

ZIP or POSTAL CODE___________

HOME PHONE (_______) _______-_________

COUNTRY______________________

OFFICE ADDRESS Line 1________________________________________________________

OFFICE ADDRESS Line 2________________________________________________________

OFFICE CITY______________________

ZIP or POSTAL CODE___________

OFFICE PHONE_(______) _______-_________

CELL PHONE_(______) _______-_________

FAX PHONE_(______) _______-_________

PROFESSIONAL DEGREE(S) ______________________________

YEAR OF GRADUATION___________

SCHOOL WHERE GRADUATED_________________________________________________

SPECIALTY(IES) ____________________________

BOARD CERTIFIED__________________________

OTHER DEGREES, SOCIETY MEMBERSHIP, ETC. _________________________________

DATE OF BIRTH___________

GENDER___________

RETIRED___________

INTEREST IN SDA CHURCH SERVICE FOR:(1-10 Scale)

SHORT TERM___________

LONG TERM___________

SPECIAL PROJECT?_______________________________________________________

INTEREST IN ADVENTIST LIFESTYLE MEDICINE_______________________

YOUR HOME CHURCH ___________________________________________

YOUR HOME CONFERENCE OR MISSION ___________________________

COMMENTS______________________________________________________

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