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.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearPlease enter date in the format shown.
Gender
Passport number
Passport Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload a copy of your passport. Title the file with your name and the word passport.

Cancelof
Occupation
Languages spoken
T- Shirt size
Prefer single or double room occupancy (Single occupancy can not be guaranteed but will be reserved for individuals when available)
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.Format: (000) 000-0000.
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

Other
Immunizations
Have you had a blood transfusion?
Have you tested positive for TB?
Healthcare Provider Information
Healthcare Provider Name

First NameLast NameSuffix
Healthcare Provider Phone Number
Please enter phone number in the format shown.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Agreements
Signature (or Signature of legal guardian if the participant is under the age of 18)
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