Trip Form – April 2023 Draft

Register for the Immersion Trip to NPH Dominican Republic
July 30 – August 5, 2023
Fees
You may pay the deposit and balance at the same time, or pay separately by dates indicated.
I want to pay the:*
- $400 non-refundable deposit due June 1, 2023
- $380 balance per person due July 1, 2023
- $780 full amount per person (deposit AND balance) due July 1, 2023
Deposit
$400 non-refundable deposit due June 1, 2023*
Enter number of travelers in the QUANTITY box.
Price: $400.00 Quantity:
Balance
$380 balance per person due July 1, 2023*
Enter number of travelers in the QUANTITY box.
Price: $380.00 Quantity:
Full Amount
$780 full amount per STUDENT due July 1, 2023*
Enter number of travelers in the QUANTITY box.
Price: $780.00 Quantity:
Total
$0.00
Participant(s)
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
Have the participants (above) recently traveled with us on an NPH USA led trip? If so, please note the name of the participant, the date, and the NPH home that they last visited:
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
Card Number Expiration Date Security Code Cardholder Name

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

Register for the Immersion Trip to NPH Dominican Republic July 30 – August 5, 2023