In order to use this form please enter the information and print the form "before" you submit it electronically if you wish to keep a copy for your records. Please mail your $200 deposit to Health Talents, PO Box 8303, Searcy, AR 72145. Unless you receive earlier confirmation via e-mail, your reservation is not considered confirmed until we receive this deposit. If a trip is already full when you submit your trip form, we will notify you of that fact within one week of submission.

Once notified of your place on the team, your trip fee balance will be due thirty days from the date of departure. The airfare portion of your trip will be due fourteen to twenty-one days from the date of purchase. Trip fee amounts can be found on the HTI Programs page.

Reservation Form
Trip Selection:
Choose a Trip:
Address:
Before proceeding: I acknowledge that the name I am providing is an exact match to my passport. If I have provided inaccurate information, I understand that I will bear the cost of changing or replacing plane tickets as a result of an error in the information I provided.
First Name
Middle Name
Last Name
Nametag Name
Healthcare Title
Gender
Male: Female:
Address 1
Address 2
City
State
Zip
Phone (Daytime)
Phone (Evening)
Email Address
Emergency Contact:
First Name
Last Name
Address 1
Address 2
City
State
Zip
Phone (Daytime)
Phone (Evening)
Email Address
Relationship
Beneficiary:
Name a beneficiary for travel insurance purposes.
Tell Us More About Yourself
Date of Birth
Children between the age of 12-17, must be accompanied by a parent or legal guardian, while children younger than 12 are not permitted on these teams.
Some medical and surgical procedures, GYN surgeries for example, are sensitive and private in nature. The HTI team leader will determine the age appropriateness for participation or observation of these procedures and/or activities.
Blood Type
In the event you or a patient needed blood as the result of an accident or following surgery, we'd like to have this information on hand. Please indicated whether or not you would be willing to donate blood in the field below.
Willing to Donate
Yes: No:
Please indicate your medical specialty in the comment box:

Currently practicing?
Yes: No:
Years practicing in your specialty?
Retired but license current?
Yes: No:
License Number
Licensing State
Other
I do speak Spanish
Church Affiliation
Passport #
Passport Expiration
Desired Departure City
Name of Medical Insurance Provider
 
Medical Insurance Number
Comment

I have read and understand the HTI Trip Policies & Disclaimer document.
(Read the Trip Policies and Disclaimer to continue)




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