Alumni Service Application

Step 1 of 9

Application Instructions
Please allow at least 60 minutes to complete this application process and complete all fields. We recommend keeping a copy of your narrative answers in a Word document on your computer, because your application will not save until it is submitted at the end. Some questions call for descriptive answers. It is to your advantage to provide as full a response as possible. Be prepared to submit a personal photo, proof of insurance, and a copy of your medical healthcare profession license (if applicable).

Contact Information
Name*
First Last Credentials
Email Address*

*must NOT be an .edu address
Alternative Email Address*
Date of Birth*
MM slash DD slash YYYY
Mobile Phone*
Please include country code.
Home Phone*
Please include country code.
Contact Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please list any programs you have previously completed with INMED, including location and dates.

Emergency Contact Information
Name of Emergency Contact*
First Last
Relationship with your Emergency Contact (i.e. Spouse, Mother, Father, etc.)*
Email Address*
Home Phone*
Mobile Phone*
Contact Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I have fully read the conditions of INMED training, have been given opportunity to ask questions, and these questions have been answered to my satisfaction. I fully accept the responsibilities below.*
I agree to the terms.
INMED Participant Responsibility Agreement
Please carefully read the following and signal your acceptance of these terms by checking the box below.

Personal Responsibility
I understand that I am ultimately responsible for all personal financial obligations associated with Institute for International Medicine (INMED) training, for the selection of my international training site, for transportation arrangements, and for securing of academic credit with my educational institution. INMED's role is only advisory and facilitory.

INMED Liability Release
I, on behalf of me and all members of my family, in consideration of the benefits to be derived, agree to be responsible for my own actions and hereby voluntarily release INMED, its employees, agents, subsidiaries, its board of Directors and officers, individually and corporately, for any and all causes of action arising in the past or the future, including any claim for injury, damage, or loss which may be sustained during the course of my involvement with INMED and including any claim arising in whole or in part from the negligence of INMED or from any other cause.

INMED Training Site Liability Release
I, on behalf of me and all members of my family, in consideration of the benefits to be derived, agree to be responsible for my own actions and hereby voluntarily release INMED's training sites, their employees, agents, subsidiaries, board of directors and officers, individually and corporately, for any and all causes of action arising in the past or the future, including any claim for injury, damage, or loss which may be sustained during the course of my involvement with INMED's training sites and including any claim arising in whole or in part from the negligence of INMED's training sites or from any other cause.

Awareness of Inherent Risks
I understand that there exist hazards, risks, and uncertainties associated with international travel and training, including but not limited to those posed by political instability, acts of violence, physical and psychological illness, extremes of weather, terrorist acts, and unavailability of modern medical care. I understand that these hazards may include theft, motor vehicle trauma, kidnapping, IEDs (improvised explosive devices), serious physical harm, HIV exposure, land mines, and snake bite.

Financial Responsibility
I agree to be responsible for all financial obligations associated with my activities related to INMED, including but not necessarily limited to all costs of transportation, passport and visa, housing, meals, study materials, and personal medical care.

Personal Health Care
I will consult with my personal physician regarding issues related to international travel, including recommended vaccinations and prophylaxis.

Code of Conduct
I agree to abide by the INMED Code of Conduct throughout all my involvement with INMED, including the entire time I may be present within a host country: I will abide by the policies of my host institutions and respect all local customs and laws. I will not consume any alcoholic beverage, tobacco produce, or illicit drug. I will not engage in any sexually explicit or provocative behavior. I will maintain professional confidentiality of all patient-related information. I agree not to post anything deemed negative, harmful, inappropriate or untrue by INMED and/or INMED sites on the Internet. If INMED or an INMED training site deems material posted on the internet as negative, harmful, inappropriate, or untrue, I agree to completely remove the content immediately. I agree to obtain consent from patients at INMED training sites prior to taking pictures or publishing any personal or medical information about them.

Use of Personal Information & Internet
I hereby authorize the release of my name, school, and other pertinent information as appropriate to medical schools, the press, and other entities that have interest in INMED. I also release any pictures and content related to my involvement with INMED that I publish on the INMED blog, on the Internet, or give to the INMED staff. I submit these pictures and content to INMED to be used by INMED in any way they choose, including but not limited to advertisements, solicitation, and publication.
Upon receiving your application and photo, INMED will immediately review your submission. You will be contacted within one week.

Alumni Service Application

Step 1 of 9

Application Instructions

Contact Information

Service-Learning Schedule

Placement Preference

Emergency Contact Information

International Healthcare Background

Religious/Spiritual Orientation

Uploads

Additional Links

Contact Info