CRNA Cuba 2023-Application

Application Form

CRNA Delegation to Cuba 2023
Please complete one application for each Professional Delegate or Guest
Application Status:*

Professional DelegateGuest- Cultural ProgramAssociation StaffDelegation Leader
Professional Delegate Name (As you wish it to as you wish it to appear on your name badge)*

PrefixProfessional Delegate First NameProfessional Delegate Last Name
Guest Name (As you wish it to as you wish it to appear on your name badge)*

PrefixAccompanying Guest First NameAccompanying Guest Last Name
Participating with (Professional Delegate Name)*

Professional Delegate First NameProfessional Delegate Last Name
Email*
example@example.com
Gender (with which most identified)
Mailing Address*

Street Address (If PO Box, please also list street address)

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number*
Please enter a valid phone number.
Emergency Contact Full Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Professional Profile

To assist our delegation leader and overseas hosts in planning your professional program, and to best meet your expectations for this delegation, please complete the following professional profile. Please indicate the highlights of your career you wish to share.
Title
Employer
Years in Field
Please list brief highlights of your professional accomplishments we may share with overseas counterparts. This can include positions you have held, associations you that have been a part of, or awards you have received.
Please list up to three areas of interest/issues you would like to discuss during the professional exchange.
To what extent do you speak Spanish?

No SpanishIntermediate proficiencyFluent
Have you been to Cuba before?

YesNo
If so, when and for what purpose?
Citizen Ambassador Program Covid-19 requirements

The Citizen Ambassador Program requires all participants to be fully vaccinated prior to travel as a condition of participation. You will be required to provide a photo of your vaccination record as part of your program preparation. Additional testing may be required for entry into the host country, we will notify you of the specific requirements, no later than 30 day prior to departure, or as a countries requirements are updated. If you have questions regarding the Covid-19 travel requirements, please contact our office.
Covid-19 Requirements*

I am fully vaccinateed (additional boosters not required)I am not fully vaccinated, however will be fully vaccinated prior to departure
Passport information- Information may be provided at a later date

Passport Required-All delegates must have a valid passport. You will be asked to provide a copy of your passport as part of the delegation preparation process. Your passport must be valid for at least six months beyond the completion of the delegation/extension/additional travel. It is recommended that passports have a minimum of 3 blank pages.
Legal Name (as it appears on your passport)*

Last NameMiddle NameFirst Name
Country of birth
Citizenship
Date of birth

MonthDayYear
Passport Number
Passport Expiration Date

MonthDayYear
Rooming Information

The Program fee is based on double occupancy, please select from the rooming options below.
Rooming Preference: *

Single RoomSpecific RoommateAssign Roommate
Single Room Supplement: If you select a single room, you will be charged the additional single supplement. Please see Program pricing in Payment section.
Roommate Requested: Roommates are assigned based on application acceptance date. Roommate assignements are announced 30 days prior to departure.
I will be rooming with...

First NameLast Name
I/we prefer

Two bedsOne bed
Optional Cultural Program Extension

Optional Cultural Program Extension Fees, including single supplement, as applies, will be invoiced 30 days after your Application has been accepted. Final Payment is due 30 days prior to the delegation convene date.
Moroccan Desert Cultural Extension

Extension program price: $2025 Single Supplement $350
Oman Desert Cultural Extension

Extension program price: $1800 Single Supplement $425
Extension Enrollment Preference:*

No EnrollmentEnroll for a Single RoomEnroll with Specific RoommateEnroll and Assign Roommate
I will be rooming with...

First NameLast Name
Single Room Supplement: If you select a single room, you will be charged the additional single supplement. Please see Program pricing in Payment section.
Roommate Requested: Roommates are assigned based on application acceptance date. Roommate assignements are announced 30 days prior to departure.
I/we prefer

Two bedsOne bed
Additional Information or Accommodations

Some delegates may require accommodations for special needs, including dietary and mobility. We will accommodate accordingly to the best of our abilities. Many of the countries with which the Citizen Ambassador Program conducts professional exchanges may not be equipped to meet your needs. We will make every effort to support requirements for travel. All rooms will be non-smoking, unless requested below. We will notify you if mobility issues would prevent you from participating in the program.
If there is any additional information you wish to add to your enrollment, please list in the Notes field below:
Authorization/Payment

Citizen Ambassador Program deposit. As the delegation will be limited, your deposit will secure your position on the delegation and your deposit will be applied towards the full program cost. $500 per delegate or guest is required.

Program Deposit only- AANA CubaProgram Fee is $4450. Single room supplement: $300. Deposit is applied to the program fee. Program Deposit of $500 is due at time of application.

$500.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Delegate signature*

Clear
Date*

MonthDayYear
Should be Empty:

Application Form

Please complete one application for each Professional Delegate or Guest

Professional Profile

Citizen Ambassador Program Covid-19 requirements

Passport information- Information may be provided at a later date

Rooming Information

Optional Cultural Program Extension

Additional Information or Accommodations

Authorization/Payment