To complete application,

enter your information in the boxes below

and​ click "Submit"

Print out a  copy of the Release of all Claims and Liability form and Conduct Guidelines form.


PLEASE READ:

ALL TRIP PAYMENTS - INCLUDING DEPOSITS

ARE NON-REFUNDABLE

If you prefer to print out a copy of the application

DO NOT SCHEDULE ANY FLIGHTS until you get instructions from ChosenIMA 

Please direct any questions to rand@chosenima.org.


Once you submit your application, we will send an email acknowledging that the application has been received. 

Please note: Passport Expiration Date must be at least six months after the completion of the trip.

If you are electing not to electronically submit your application and/or forms, send all necessary materials to this address:


Chosen International Medical Assistance

3638 W. 26th Street

Erie, PA 16506

$250 Deposit expected to be made with submission of application.


Trip Cost Balance DUE 30 days prior to the first day of the trip.


COST OF THE TRIP IS $975* plus airfare to Cancun. 


IF YOU ARE STAYING FOR 2 CONSECUTIVE WEEKS, THE COST IS $1,600* plus airfare to Cancun FOR THE 2 WEEKS. 


After we receive your application, deposit, credit card information, and/or PayPal payment, ChosenIMA will connect you to our travel agent to schedule your flight. ChosenIMA will pay for the flight, and you will reimburse ChosenIMA so the total amount you pay for this trip is tax deductible. 


​*Above rates are based on double or triple occupancy.  You may request a single room at a rate of $1275 for one week, or $2100 for two weeks.  Be sure to indicate this choice on your application.

All Applicants:


If applicable, please email the following to Randy King at rand@chosenima.org:


-Recent Photo

    

-Medical/Dental Professionals must submit a copy of their diploma, credentials, privileges and current professional license. In addition, Anesthesia Providers - please send a copy of your DEA - controlled substance registration certificate


- All Physicians: Please send a Curriculum Vitae and current list of surgical privileges, if applicable.


- All Applicants must sign and submit the Release of all Claims and Liability and Conduct Guidelines form. See Below.