Institute for International Medicine Withdrawal Request

Institute for International Medicine Withdrawal Request

Please complete the form below.
INMED Learner ID Number*
Date of Birth*

MonthDayYear
Date
Full Name*

First NameLast Name
Phone Number*
Email Address*
example@example.com
Requesting Withdrawal From A*

CourseProgram
Program Accepted Into*
Academic Credit Courses

Epidemiology CourseEmergency Pandemic Control CourseHealthcare Leadership & Administration CourseHealthcare for Marginalized Americans CourseInternational Health Professions Education CourseInternational Healthcare Ethics CourseInternational Refugee Care CourseLifestyle Health Course
Professional Qualifications Courses

Professional Certificate Course in Advanced Mother Baby Outcomes (AMBO)Professional Certificate Course in Essential Care for Every Baby and Essential Care for Small BabiesProfessional Certificate Course in Helping Babies Breathe (HBB)Professional Certificate Course in Ultrasound for Primary Care
Four Week Courses

Service Learning - International MedicineService Learning - International NursingService Learning - International Public Health
Reason for Withdrawal Request*
Upon submission of this form, I would like a*

Refund (if eligible per MIH Refund Policy)Deferral to a Later TimeComplete WithdrawalSwitch from the MIH to a Diploma Program
Length of Deferral
Ex: one-year deferral; yearlong deferral; until 2023 Spring Term
Should be Empty: