Trip Form Test – Individual

Register for the Immersion Trip to NPH Dominican Republic
March 21 – 28, 2026

Cost: $1,140 per person

You may pay the deposit and balance at the same time, or pay separately by dates indicated.

Non-refundable deposit per person due by December 22, 2025 Quantity*
Price: $400.00
Balance per PERSON due January 21, 2026 Quantity*
Price: $740.00
Total
$0.00
Participant Information*
If you are registering for more than one participant, click (+) at far right to add information for each one.
Full, legal name (as it appears in your passport) Date of Birth (MM-DD-YYYY) Email address for each ADULT participant or GUARDIAN’s email address for minors
Comments:

Billing Information
Name*
First Last
Company/Organization
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
CAPTCHA

Full, legal name (as it appears in your passport)	Date of Birth (MM-DD-YYYY)	Email address for each ADULT participant or GUARDIAN’s email address for minors