BNN x Yuyi Africa presents..

BNN x Yuyi Africa presents..

IMMERSION Africa! A 7-day immersion experience for medical professionals that includes safari and hands on clinical service opportunities in Kenya!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
Solo!1-23-55+
2) What is your title?*
Please select the date of your trip arrival.*
Please select the payment you agree to. Note: if you pay the initial deposit of $500, your remaining balance of $1495 will be due 3 weeks prior to your trip.*
PLEASE SUBMIT PAYMENT OF $500 or $1995 via Zell to Kylie Stores 412-726-1261 at the completion of this application
PassportKenya VisaMalaria PillsYellow Fever VaccineFlight round trip flight to Kenya and back to your destination
4) Additional Comments or Feedback.
I have read all the terms and conditions of this trip, I understand my payment is non-refundable, and I will pay the balance necessary at the conclusion of this application*

Powered by Jotform SignClear
Should be Empty: