Withdrawal Form - ACEM Emergency Medicine Certificate and Associateship Training Programs (NSTP838)

Withdrawal Form - ACEM Emergency Medicine Certificate and Associateship Training Programs (NSTP838)

To withdraw from your program please complete the following declaration
Before submitting your application to withdraw, please take some time to review the Policy on Former Trainees Re-Entering Training Programs.

Please ensure that you download any copies of assessments from your Assessment Summary prior to completing the online request form as once you are no longer an EMCD trainee these assessments are no longer accessible. To obtain these assessments once you have been withdrawn, an administrative fee would apply
Name*

First NameLast Name
ACEM ID*
Your Email*
example@example.com
3. Select the Program you are enrolled in*

Emergency Medicine CertificateAssociateship in Intermediate Emergency Medicine (Formerly EMD)Associateship in Advanced Emergency Medicine (Formerly (EMAD)
4. What is the reason you are withdrawing?*

Career change – medicalCareer change – non-medicalJoined another training programJoined the FACEM training programFinancial considerationsFamily commitmentsHealth issuesPersonal reasonsDissatisfied with the training programUnable to obtain a suitable training placementUnable to complete assessments within the program timeframePrefer not to answerOther
If you would like to provide further feedback regarding your training experience, please add your comments below
1. I understand that the withdrawal is effective from the date of the submission of this form to the College and no further training or assessments will be accredited to my training record from this date.

2. I understand that I will only be granted a refund if I meet the ACEM Refund Policy eligibility requirements.

3. I understand that I will no longer be enrolled in the applicable EMCD Training Program and will not have access to the educational content on the ACEM website.

4. I understand that any documentation requested from my trainee file post withdrawal will require payment of an administration fee.
Please confirm that you understand the above conditions of your withdrawal*
The College will notify you once your application to withdraw has been finalised.

If you have any queries regarding the terms and conditions, please contact the EMCD Team on (03) 9320 0444.
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