HA Mexico 2025 Application

Vision Expedition Application

Mexico November 2025
Itinerary
November 11 - Arrive in Phoenix anytime. (Hyatt Place Tempe/Phoenix Airport)
November 12 - Travel day. Depart Phoenix by van early morning arriving in Puerto Peñasco by mid-afternoon. Clinic set-up. (Playa Bonita Resort)
November 13, 14, 15 - Vision Clinics
November 16 - Free day. (beach, swimming, shopping, relaxation)
November 17 - Travel day. Depart Puerto Peñasco early morning for return to Phoenix by early afternoon. (Schedule flights no earlier than 4:00 PM)
Participant Information
Participant Name*

First NameMiddle NameLast NameSuffix
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter phone number in the format shown.
Date of Birth*

MonthDayYear
Please enter date in the format shown.
Gender*
Passport number
Passport Expiration Date

MonthDayYear
Date
Upload a copy of your passport. Title the file with your name and the word passport.

Cancelof
Occupation*
Languages spoken*
T- Shirt size*

X-SmallSmallMediumLargeX-LargeXX-Large
Prefer single or double room occupancy (Single occupancy can not be guaranteed but will be reserved for individuals when available)*

SingleDouble
I can offer my experience in the following areas:*
Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone Number*
Please enter phone number in the format shown.
Emergency Contact Email*
example@example.com
Personal Health Information
Allergy Information*
List any known allergies. Include food, animals, bites, stings, and medications.
Current Medications*
List your current medications. Include name, dosage, and frequency.
Personal Health History*

AnxietyAsthmaBladder/kidney problemsBlood/circulatory problemsHeart problemsCancerDiabetesGI/stomach problemsHypertensionLiver problemsMigrainesStrokeSeizures/epilepsyPulmonary problemsNone of the aboveOther
Immunizations*

ChickenpoxCOVID-19Hepatitus AHepatitus BInfluenzaMMRPneumoniaTetanusTyphoidYellow FeverOther
Have you had a blood transfusion?*

YesNo
Have you tested positive for TB?*

YesNo
Healthcare Provider Information
Healthcare Provider Name*

First NameLast NameSuffix
Healthcare Provider Phone Number*
Please enter phone number in the format shown.
Healthcare Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Information
Insurance Provider*
Name of Policy Holder*
Group Number*
Account Number*
Insurance Provider Phone Number (24 hour)*
Please enter phone number in the format shown.
Agreements
Signature (or Signature of legal guardian if the participant is under the age of 18)*

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Email*
example@example.com
Should be Empty:

Vision Expedition Application

Itinerary

Participant Information

Emergency Contact

Personal Health Information

Healthcare Provider Information

Health Insurance Information

Agreements