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A. I Love Taiwan Mission 2011 (June28 - July14)
B. The Youth Forum of the National Fate of Taiwan
(July15-17)
Application Form Date29 04 - 2011Name
PassportHmar Lalchhanhima
Chinese CharactersGender
F
M
Photo
Date of Birth 4444thththth JulyJulyJulyJuly,,,, 1980198019801980
Passport Number HHHH 9353893538935389353833333333
Church Presbyterian CPresbyterian CPresbyterian CPresbyterian
Church of Indiahurch of Indiahurch of Indiahurch of India
Occupation Self EmployedSelf EmployedSelf EmployedSelf Employed
School / Major Bachelor ofBachelor ofBachelor ofBachelor of
CommerceCommerceCommerceCommerce
Address Aizawl, Mizoram. IndiaAizawl, Mizoram. IndiaAizawl,
Mizoram. IndiaAizawl, Mizoram. India
Tel/ Fax(T +91+91+91+91 98232102982321029823210298232102
(FEmail
Emergency
contact
Name: RRRRosieosieosieosie
LalduhawmiLalduhawmiLalduhawmiLalduhawmi Phone number+91
9862373518 Relation: SpouseSpouseSpouseSpouse
Language
Ability
Taiwanese Mandarin English Others
Speak
Read & Write
Listen
I wish toI wish toI wish toI wish to applyapplyapplyapply
forforforfor (please select one or both, which you would like to
participate
A. I Love Taiwan Mission 2011 (June28 July14
B. The Youth Forum of the National Fate of Taiwan (July1517
Have you ever participated in ILT?Have you ever participated in
ILT?Have you ever participated in ILT?Have you ever participated in
ILT?If yes, please note which year and attend which church in
Taiwan.
No Yes, , church
Special Skills Music Drama Art
Computer StoryTelling Instruments Field of
interest
Kids teaching leading Teenagers Community service
Environmental concerns Instruments
Brief
Introduction
of yourself
Special Need Vegetarian Allergy Others
Parent
Endorse
Applicant Sign
Local Church
Endorse
Please fill it out and send back to your denomination contact
person.
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I Love Taiwan Mission 2011Health Agreement and Liability Release
FormParents and Participants: This form is MANDATORY for
participation. Please read itcarefully and sign where indicated.
Participants over 18 years of age do not requireparental consent
but we still need this completed form on file.
Participants Name: Hmar Lalchhanhima Date of Birth : 04. 07
1980
Home Address : Mission
Vengthlang___________________________________
City: Aizawl State/County/Country: Mizoram, India Zip:
796001_______
E-mail
Address:_________________________________________________________
In case of emergency, notify : Rosie Lalduhawmi Phone: (+91)
9862373518
Health Statement:Is the participant currently under treatment
for a medical condition? Yes /NoIf yes, please
describe:____________________________________________________Has
the participant been under treatment for a medical condition in the
past? Yes /NoIf yes, please
describe:____________________________________________________List
all medications the participant is currently taking:
____________________________List any known allergies to medication:
_______________________________________
Parental Consent:
I, H.Zahmuaka (name of parent/guardian) give permission for the
I Love TaiwanMission Camp staff and its affiliates to act in my
behalf to approve appropriate medical
treatment for my son/daughter/participant Hmar Lalchhanhima
should anemergency medical treatment be necessary and will make any
necessary financialreimbursements.
I Hmar Lalchhanhima the participant, am of lawful age and
legallycompetent to sign this Medical Release.
I understand that the terms herein are contractual and are not a
mere recital; and that Ihave signed this document as my own free
act. I agree to release and hold harmless theI Love Taiwan Mission
Camp staff and its affiliates from any liability for decisions
madepursuant to their authorization.
I have fully informed myself of the contents of the Medical
Release by reading it and thatthe medical and insurance information
I give below is accurate.Health Insurance Carrier:
_____Nil________________ Policy #: _______Nil_________
Policy Holders Name: __________Nil _________ Doctors Name:
_______________
Parent / Guardian Signature: ____________________________ Date:
29 04 - 2011
Participant Signature: __________________________________ Date:
29 04 - 2011
