International Service-Learning Application

Application Instructions
Note: Submission of this application is only for individuals who have already been accepted into an INMED Master’s Degree in International Health (MIH) program.
Name*
First Last Credentials
Email*

*must NOT be an .edu address
Date of Birth*
MM slash DD slash YYYY

Are you requesting a two-week international service-learning experience?*
- Yes
- No
International service-learning is ideally at least four weeks in duration. This length of time significantly increases the likelihood that the learner will experience a substantial growth opportunity. However, INMED realizes that some learners have professional commitments that preclude them from being absent for that duration. Therefore, INMED offers an exception to the four-week requirement. If accepted into the International Service-Learning Reduced Duration Pathway, the requirement is reduced to at least two weeks on location followed by composing a quality improvement project.
Are you submitting an alternate (non-INMED) training site for approval via equivalency?*
- Yes, a past experience
- Yes, an upcoming experience
- No, I'm applying to an INMED training site

Equivalency Training Site*
If you are an equivalency applicant with a service-learning experience at a non-INMED training site, please enter the name and a detailed description of your training site below (including website, if available).
Equivalency Dates (Start-to-End Dates)*
On-Site Preceptor Contact Name*
First Last
On-Site Preceptor Email*

Please click Next
Service-Learning Schedule
International service learning experiences are offered year round. Students and junior resident physicians must be at least 4 weeks in duration. Practicing professionals and final-year resident physicians must be at least two weeks in duration. Please list in order of preference the 1-3 dates you are available for the international service learning:
Departing Date Preference #1 (MM/DD/Year)*
MM slash DD slash YYYY
Returning Date Preference #1 (MM/DD/Year)*
MM slash DD slash YYYY
Departing Date Preference #2 (MM/DD/Year)
MM slash DD slash YYYY
Returning Date Preference #2 (MM/DD/Year)
MM slash DD slash YYYY
Departing Date Preference #3 (MM/DD/Year)
MM slash DD slash YYYY
Returning Date Preference #3 (MM/DD/Year)
MM slash DD slash YYYY

Placement Preference
While we 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 regarding other options. INMED does not guarantee that all applications will be provided the opportunity to complete the International Service-Learning. Click this link to read detailed descriptions of each INMED Training Sites: INMED Training Sites https://www.inmed.us/training-sites/
Enter the full name of your first choice training site below.*

Ex: Angola - CEML Hospital
Enter the full name of your second choice training site below.*
Enter the full name of your third choice training site below.*
Prerequisite Participation Dates:

Each INMED MIH participant must first successfully complete the corresponding INMED Professional Certificate Course. If you have already completed this Certificate Course through INMED, or have scheduled an upcoming Certificate Course, please enter the course dates above.
Do you have any friends with whom you wish to be placed? If so, please list their name(s) below:
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.

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

Religious/Spiritual Orientation
INMED accepts applicants without regard to religious or spiritual preference. Most INMED international training sites are faith-based medical ministries. The following information is helpful to place applicants at the optimum international site.
What is your religious/spiritual orientation?*
How important is this orientation to your day-to-day life?*
How does your religious/spiritual orientation affect your desire to study international medicine?*
How would you interact with people of a different spiritual orientation than your own?*
Is there anything else you would like INMED to know?*

Proof of Health Insurance
Drop files here or

Max. file size: 50 MB.
Upload scanned copy of health insurance card.
Passport Data Page
Drop files here or

Max. file size: 50 MB.
Type Your Passport Number
Country of Issue
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.
Please click "Add to Cart" below, then "View Cart" on the following page.

International Service-Learning Application

MIH International Service-Learning Application

MIH International Service-Learning Application

Step 1 of 8

Application Instructions

Service-Learning Schedule

Placement Preference

Emergency Contact Information

Religious/Spiritual Orientation