Mission Trip Application

Apply to join an AVA mission trip to Hospital Nacional de San Benito (HNSB). Fields marked (required) must be completed. For general information about the trips, see the General Information handout.

Mission Trip Dates (required)

Name

First Name

Last Name

Address

Country

Address Line 1 (required)

Address Line 2

City (required)

State (required)

ZIP Code (required)

Email (required)

Phone (required)

Date of Birth

Gender

Employment Information

Employer

Job Title

Professional Medical Designation

If you selected "Medical, Other", please describe:

Specialty

Professional (Medical) License Type

Professional License Number

License Expiration Date

Are you a Student or Resident?

School/University Attending?

Degree/Program/Specialty

Projected Completion Date

Mission Trip Information

Passport Number

Issuing Country

Passport Expiration Date

Name(s) of anyone traveling with you:

Spanish Proficiency

Emergency Contact Name

Relationship

Phone

Donation Fee: $500 (required)

To ensure the continued success of our mission trips and the vital work we carry out, we kindly request a donation of $500 from each applicant. This contribution plays a crucial role in covering the various expenses associated with organizing and executing our trips effectively, such as travel arrangements, accommodation, supplies, and support for the communities we serve. Please use the "Donate" button at the top right of the website.

I understand.

Additional Comments

If you have any questions or concerns, you can also email aid.via.action@gmail.com.