2027 NYRN MEDICAL MISSION REGISTRATION
We're thrilled that you're considering joining our mission to bring positive change to communities in need! Your commitment is the driving force behind our impact, and we can't wait to have you on board. If you have any questions, feel free to reach out to Rony Curvelo at rony.curvelo@nyreliefnetwork.org or 347-830-4885

Form of Payment:
VENMO: @NYRNMISSIONS
PAYPAL: New York Relief Network
ZELLE: 347 830 4885
Sign in to Google to save your progress. Learn more
Email *
First name (as shown as passport) *
Last name (as shown as passport) *
Email *
Phone Number *
Street Address (e.g. 123 Main St.) *
City/Town *
State *
Zip/postal code *
You are signing up as...
ALL ARE WELCOME. We just ask so we can better understand who’s joining us *
Hospital/Unit if none add N/A *
Are you a Union Member? Which one?  If none add N/A *
Choose single or double. *
Choose your 2027 NYRN Mission Trip: *
Captionless Image
Required
Waiver Form Documentation NYRN agreement Page 1 *
Captionless Image
Waiver Form Documentation NYRN agreement Page 2
 *
Captionless Image
Waiver Form Documentation NYRN agreement Page 3
 *
Captionless Image
Waiver Form Documentation NYRN agreement Page 4
 *
Captionless Image
Waiver Form Documentation NYRN agreement Page 5 *
Captionless Image
Waiver Form Documentation NYRN agreement Page 6 *
Captionless Image
Waiver Form Documentation NYRN agreement Page 7 *
Captionless Image
I have read all five pages of the NYRN Waiver Form Documentation, and I further acknowledge that I agree and

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I UNDERSTAND THAT I MAY REVIEW THIS AGREEMENT WITH THE COUNSEL OF MY CHOOSING. I AM AWARE THAT THIS IS A BINDING LEGAL CONTRACT BETWEEN ME AND NYRN AND/OR ITS AGENTS, AND SIGN IT KNOWINGLY, VOLUNTARILY, AND OF MY OWN FREE WILL.

Type I ACCEPT to agree with NYRN terms and conditions.
 *

I hereby confirm that all the information provided is accurate, and I agree to comply with the medical mission organizers' guidelines and requirements. 

 *
Required
As part of your registration you must send a copy of your passport to this email: Rony.curvelo@nyreliefnetwork.org.   
 If you have previously sent this information you don’t have to do this again.
 *
Required

PLEASE READ IMPORTANT INFORMATION:

* All participants must visit the State Department travel advisory and be aware of the safety level for the host country to which they are traveling.

 * Participants will be responsible for adhering to all vaccination requirements of the host country.

 * Participants should visit the CDC webpage for requirements and travel advisories for specific countries.

 * All participants must comply with local authorities’ requirements. 

* All participants must agree and sign the waivers of liability, photo release and code of conduct

*
Required

PLEASE READ IMPORTANT INFORMATION:

* AIRFARE IS NOT INCLUDED 

* Fee Includes: Hotel, and local transportation.

 * The registration will be accepted after a $350 deposit is made to NYRN. 

* Participation fees are subject to change. 

* Itinerary is subject to change.

 * Participation fee is per person and is an estimate.

 * The deadline for full payment is three months before the departure date. 

* The final cost will be confirmed three months before departure. 

* All Medical Missions are also educational 

* All participants must comply with local authorities’ requirements.

 * VISA fees not included


*
Required
Form of Payment is through Zelle, Venmo or PayPal. Below are the details.  
VENMO: @NYRNMISSIONS
PAYPAL: New York Relief Network  
ZELLE: 347 830 4885 
IMPORTANT: Your registration will only be complete when you send in the deposit in the amount of $350 per mission. If your mission is in 3 months or less please send full payment.
 *
Required
 PLEASE READ. FINAL NOTES. VERY IMPORTANT * Your registration will only be complete when you send in the deposit in the amount of $350 per mission/ per person. IF YOUR MISSION IS IN 3 MONTHS OR LESS PLEASE SEND FULL PAYMENT.  * When you use Venmo, or Paypal please inform the name of the country you are making the deposit for, EXCEPT for CUBA, that you should just write ISLAND.  * Three months from departure date, the participation fee is NOT REFUNDABLE *
Required
Personal Property Liability Disclaimer  By participating in any trip, mission, event, or activity organized by the New York Relief Network (NYRN), you acknowledge and agree to the following:  1. Personal Responsibility for Belongings All participants are solely responsible for the care, security, and supervision of their personal property, including but not limited to luggage, bags, electronics, documents, money, and personal valuables.  2. No Organizational Liability NYRN, its directors, officers, staff, volunteers, partners, and affiliates shall not be held liable for any loss, theft, damage, or misplacement of personal belongings at any time during travel, lodging, transportation, mission activities, or free time—whether such incidents occur in hotels, airports, vehicles, mission sites, or any public or private location.  3. No Duty to Safeguard Items NYRN does not assume or accept any duty to guard, store, or protect participants’ personal items. Participants should not leave belongings unattended and are encouraged to secure valuables or keep them in their possession at all times.  4. Travel & Transport Disclaimer NYRN is not responsible for any lost or delayed baggage, damaged luggage, or items mishandled by airlines, transportation companies, hotels, or third-party service providers.  5. Participant Agreement By attending the trip or mission, the participant expressly releases NYRN from any claims arising from loss, theft, damage, or disappearance of any personal property and agrees that they retain full responsibility for their belongings at all times. *
Required
How did you learn about NYRN? (Please select all that apply)
I understand and agreed that if after I send the registration and no longer want to participate
 I will send a message to Rony Curvelo at rony.curvelo@nyreliefnetwork.org or 347-830-4885
 informing of my decision so my name can be removed from the list and opening a spot to somebody else
 *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms