To use this form please enter the information and print the form before you submit it electronically. Please mail the form and your non-refundable $200 deposit to Health Talents, PO Box 8303, Searcy, AR 72145. Your reservation is not considered confirmed until we receive this deposit. Total trip fee amounts can be found on the HTI Programs page. You will be notified by Health Talents concerning your place on the trip. Once notified of your place on the team, your trip fee balance will be due thirty from the date of departure. You will be invoiced for any applicable connecting flights approximately at least forty days prior to your departure.

Reservation Form
Trip Selection:
Choose a Trip:
Address:
First Name
Middle Name
Last Name
 (Enter name as it appears on your passport)
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:
Other
I do speak Spanish
Church Affiliation
Passport #
Desired Departure City
Comment

I have read and understand the HTI Trip Policies & Disclaimer document.



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