Women's Health Nurse Practitioners Delegation

United States Women's Health Nurse Practitioners

US Delegation- December 2025
Application Form
Please complete one application for each Professional Delegate or Guest
Professional DelegateGuest- Cultural ProgramAssociation StaffDelegation Leader
Professional Delegate Name *

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

PrefixAccompanying Guest First NameAccompanying Guest Last NameSuffix
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.Format: (000) 000-0000.
secondary/mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Full Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
No SpanishIntermediate proficiencyFluent
YesNo
If so, when and for what purpose?
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 Name (if on your passport)First Name
Date of birth

MonthDayYear
Country of birth
Citizenship
Passport Number
Passport Expiration Date

MonthDayYear
Rooming Information

The Program fee is based on double occupancy, please select from the rooming options below.
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.
Professional Program: I will be rooming with...

First NameLast Name
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 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

$500 program deposit is required for each professional delegate or accompanying guest. The program deposit will be applied towards the full program cost and is refundable within 30 days of application or up to 90 days prior to the program convene date.

Program Deposit - Women's Health Nurse Practitioners

Program fee is $4425 (Includes flights roundtrip Miami - Havana). 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:

United States Women's Health Nurse Practitioners

Application Form

Please complete one application for each Professional Delegate or Guest

Professional Profile

Passport information- Information may be provided at a later date

Rooming Information

Additional Information or Accommodations

Authorization/Payment