Register for a Mission

Registration Form

*All fields are required. Please mark the field with n/a if it does not apply.

Cost is round trip air from JFK only, transfers, tips, emergency evacuation insurance, hotel and meals. Alcoholic and non-alcoholic beverages are not included in mission cost. Team members departing from other cities will receive an adjusted rate.

"*" indicates required fields

DISCLAIMER:
Blanca’s House is not responsible for any change(s) to the location of a medical mission due to the host government’s decision to relocate the site of delivery of medical services based on their review of need.

Please select the mission that you are interested in attending:*

March 9-12, 2023: General Surgery - Guayaquil, EC

Mission Cost: $2,116.00 (Single occupancy) / $1,996.00 (Double occupancy)

Consent*

I understand I will be responsible for the round-trip airfare payment of $885 required in the application.*

Name*

First Last

Medical Specialty/Occupation*

Area of Focus*

For example, if you are a Nurse and you work primarily in the OR, then that would be your area of focus.

Current Place of Work/Study*

Current Place of Employment/Current University or College of Study:

Date of Birth*

Are you under 18 years of age?*

Yes

Children under the ago of 18 must be accompanied by a parent.
Please provide contact information for your parent that will be attending the mission with you:

Name of parent or legal guardian*

Phone of parent or guardian

Email of parent or guardian

Relationship to you

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Username*

Password*

Enter Password Confirm Password

Please remember your password. If you are accepted into the mission, you will need this to log in and complete the application. THANK YOU

Cell Phone*

Name of person who referred you:*

Reference Name*

Phone*

Please attach your resume (PDF) file type only, 2mb limit):*

Accepted file types: pdf, Max. file size: 128 MB.

By typing my initials in the following box, I understand that I am only filling out the registrations form at this time. If I am accepted, I agree to fill out a full application, including my medical history, emergency contacts, and various other forms:*

Date*

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You will receive an email with link to the application once your reservation is submitted.

This field is for validation purposes and should be left unchanged.

Registration Form

MISSION PHOTOS

TAX INFORMATION

TAX INFORMATION