Destination:
Neiva, Colombia
Home ::
2006 schedule
Click
Here for Online Registration Form (You
must be an approved
Team Member before
Registering)
or
~~DOWNLOAD
MEMBERSHIP FORMS
HERE~~
IF the chart below shows
that a
CV, and or copy of
your medical
license is needed,
please fax or email
them to
the office right
away. We need
these to secure your
working permits in
country.
|
This is Healing the Children's
13th trip to Neiva!
|
| Dates: May
7 - 15, 2006 |
| Sponsor: Neiva
Chamber of Commerce |
| UPDATES: If you
have not sent in your paperwork please do so immediately.
Important: Please limit
your personal luggage to one bag!
|
Site Contact Info.: Neiva
Chamber (011-578-871-3677)
email: camacom@neiva-server1.usurcolombia.com
Chamber President- Ariel Rincon Machado, Trip Coordinator- Carlos
Fajardo e-mail neivatur@telecom.com.co
Chamber phone- 011-578-871-3677 Fax 011-578-871-1895
Hotel : Hotel Chicala
|
| Administrative Contact: Robert
Sariego
phone 908-470-2682 fax 908-470-2685
|
|
Participants: |
|
|
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|
|
|
|
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Surgery |
License to Practice |
CV |
Credit Card Auth |
Clinical Specialty Form |
Health Form |
Release of Liability |
Passport Info |
2005 Dues |
Air Fare
|
|
David Hoffman,
Team Leader |
in
|
in
|
NA
|
in |
in |
in |
in |
sending in check
|
in
|
|
Sidney Eisig |
in
|
in
|
in
|
in
|
in
|
in
|
in
|
cc
|
cc
|
|
Maria Fe Garcia |
in
|
in
|
in
|
in |
in |
in |
in |
cc |
NA
|
|
Snehal Patel
(Res) |
in
|
in
|
in
|
in |
in |
in |
in |
cc |
in
|
|
Greg Urfrig (Res)
|
in
|
in
|
in
|
in
|
in
|
in
|
in
|
cc
|
in
|
|
Sergio
Sanchez Santolino (Res)
|
in
|
in
|
in
|
in
|
in
|
in
|
in
|
cc
|
N/A
|
|
Surgeons/Physician
Friends from Colombia |
License to Practice |
CV |
credit card auth |
Clinical Specialty Form |
Health Form |
Release of Liability |
Passport Info |
2005 Dues |
Air Fare
|
|
Jorge Enrique Penuela
|
n/a
|
n/a
|
n/a
|
n/a |
n/a |
n/a |
n/a |
n/a |
n/a
|
|
Andres Ferro |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a
|
|
Alberto Trespalacios |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a
|
|
Pediatrics |
License to Practice |
CV |
credit card auth |
Clinicall Specialty Form |
Health Form |
Release of Liability |
Passport Info |
2005 Dues |
Air Fare
|
|
Arthur
Buonaspina |
in |
in |
in |
in |
in |
in |
in |
cc |
cc
|
|
Rafael
Nunez |
in |
in |
in |
in |
in |
in |
in |
cc |
cc
|
|
Richard
Sidlow |
in |
in |
in |
in |
in |
in |
in |
cc |
cc
|
|
Anesthesiology |
License to Practice |
CV |
credit card auth |
Clinical Specialty Form |
Health Form |
Release of Liability |
Passport Info |
2005 Dues |
Air Fare
|
|
Antonio Luciano |
in |
in
|
N/A |
in |
in |
in |
in |
in |
in
|
|
Tommy Eric Back |
in
|
in
|
need |
in
|
in |
need |
in
|
need |
N/A
|
|
Abraham Berkowitz |
in
|
in
|
in |
in
|
in |
in |
in
|
in |
in
|
|
Faiz Hasham |
in |
in
|
in |
in |
in |
in |
in |
in |
in
|
|
Roxana
Belciu-Kerns |
in |
in
|
in |
in |
in |
in |
in |
cc |
cc
|
|
Juan
Quintana
|
in
|
in
|
in
|
in
|
in
|
in
|
in
|
cc
|
cc
|
|
Maria
Sanz
|
in
|
in
|
N/A
|
in
|
in
|
in
|
in
|
in
|
N/A
|
|
Maria Diaz-Vega |
N/A |
N/A
|
in
|
in |
in |
in |
in |
in |
in
|
|
Linda
Kovitch |
need
|
in
|
need
|
in
|
need
|
need
|
in
|
need
|
need
|
|
Nursing |
License to Practice |
CV |
credit card auth |
Clinical Specialty Form |
Health Form |
Release of Liability |
Passport Info |
2005 Dues |
Air Fare
|
|
Joseph
Figueroa
|
N/A
|
N/A
|
n/a |
in
|
in |
in |
in
|
in |
in
|
|
Erica Maule |
in
|
in
|
in
|
in
|
in
|
in
|
in
|
in
|
in
|
|
Robert Rathman |
in
|
N/A
|
in |
in
|
in |
in |
in
|
cc |
in
|
|
Ann
Sariego |
in
|
in
|
N/A
|
in
|
in
|
in
|
in
|
in
|
in
|
|
Sonia Winniczek |
in
|
N/A
|
in
|
in
|
in
|
in
|
in
|
cc
|
in
|
|
Elena Hopkins |
in
|
N/A
|
in
|
in
|
in
|
in
|
in
|
in
|
in
|
|
Rose Michelle Vega |
need
|
N/A
|
need
|
need
|
need
|
need
|
need
|
in
|
in
|
|
Guests |
License to Practice |
CV |
credit card auth |
Clinicall Specialty Form |
Health Form |
Release of Liability |
Passport Info |
2005 Dues |
Air Fare
|
|
Zev Balsen
|
N/A
|
N/A
|
in
|
N/A
|
in
|
in
|
in
|
in
|
in
|
|
Administration |
License to Practice |
CV |
credit card auth |
Clinical Specialty Form |
Health Form |
Release of Liability |
Passport Info |
2005 Dues |
Air Fare
|
|
Robert
Sariego |
N/A |
N/A |
in |
N/A |
in |
in |
in |
cc |
in
|
Flight
Itinerary : TBA
Please
note: If for any
reason you are
unable to travel it
is important that
you contact the Team
Leader or Admin
right away so that
your spot can be
filled. If you
get sick and are
unable to travel at
the last minute,
please also contact
the airline and
notify them that you
will not be using
your ticket.
This will allow us
to negotiate (with a
doctors note) a
replacement voucher
for a future
trip. If you
do not notify them
before the flight
leaves the ticket
will be lost.
Fax Forms to HTC at 860-350-6634
Mail Forms to HTC at P.O. Box 129, New Milford, CT 06776
E-mail to mlaw@htcne.org
|
