INMED - Institute for International Medicine

Institute for International Medicine
Equipping healthcare professionals to serve the forgotten

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INMED International Public Health Diploma Application

Instructions

Please allow at least 60 minutes to complete this application process. Currently, it is not possible to save your unfinished application and then later return. Be prepared to submit a personal photo and a $100 non-refundable application fee, payable via credit or debit card, or by personal check.

Please complete all fields. Some questions call for descriptive answers. It is to your advantage to provide as full a response as possible.

We highly recommend you save a personal copy of your application in case it is not received by INMED. You may save each completed page as a web page, print a hard copy of each completed page, and/or save your responses in a Word document.

Step 1 of 4

Date of application: 2/4/2012

General Information

Today's Date:
First name:
Last name:
Age:
Permanent E-mail Address:
Alternate E-mail Address:
Home phone:
Mobile phone:
Permanent Mailing Address Line 1:
Permanent Mailing Address Line 2:
City:
*Home Region:	If you selected "Outside US/Canada", please choose your Country below.
Zip Code:
*Home Country:
T-shirt Size:
Academic Degree:
Specialty/Title:
Occupation:
How Did You First Hear Of INMED?:
Please Describe How You Heard:
Marital status:
Birth date:
Sex:
Country of Citizenship:

Academic Institution Complete this section if you are currently enrolled as a student, resident or fellow.

Year of Training:
Core Rotations & Electives that will be completed prior to International Elective (if applicable):
Academic Institution name:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:
School/Residency phone:
Academic Coordinator's First Name:
Academic Coordinator's Last Name:
Coordinator's e-mail:
Coordinator's phone:

Emergency Contact Information

Emergency Contact's First Name:
Emergency Contact's Last Name:
Relationship:
E-mail Address:
Home phone:
Mobile phone:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:

International Public Health Intensive Hybrid Course

Please refer to the International Public Health Intensive Hybrid Course Dates and enter the dates of which Course in which you wish to participate:

Service Learning Schedule

Electives are offered year round, and generally must be at least 4 weeks duration. Please list in order of preference 1-3 the dates you are available for this elective:

1. Departing Date Returning Date

2. Departing Date Returning Date

3. Departing Date Returning Date

Placement Preference

To read detailed descriptions of each INMED International Public Health Training Site, please click here.

1st choice:
2nd choice:
3rd choice:
While we will endeavor to place you at the location of your choice this may not be possible. If that is the case, we will communicate with you in regards to other options.

Do you have any friends you wish to be placed with? If so please list their name(s):
In an effort to respect cultural norms of host nations, INMED does not send students who are dating to the same training site simultaneously.

Do you have any family members you wish to accompany you? If so please list their name(s), ages, and relationship to you:

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