8/7/2019 Cinnie

http://slidepdf.com/reader/full/cinnie 1/2

 

A. I Love Taiwan Mission 2011 (June28 - July14)

B. The Youth Forum of the National Fate of Taiwan (July15-17)

 Application Form  Date   29 – 04 - 2011 Name

PassportHmar Lalhmangaihi

Chinese CharactersGender 

F M

 

Photo

Date of Birth 14141414thththth August, 1982 August, 1982 August, 1982  August, 1982 Passport Number G. 1750302G. 1750302G. 1750302G. 1750302

Church PCIPCIPCIPCI Occupation Self EmployedSelf EmployedSelf EmployedSelf Employed

School / Major Master of Social Work (MSW…Master of Social Work (MSW…Master of Social Work (MSW…Master of Social Work (MSW…

 Address  Aizawl, Mizoram, India Aizawl, Mizoram, India Aizawl, Mizoram, India Aizawl, Mizoram, India

Tel/ Fax(T… +91919191 985：927117985：927117985：927117985：927117

(F…Email cinnie_07@yahoo.co.incinnie_07@yahoo.co.incinnie_07@yahoo.co.incinnie_07@yahoo.co.in 

Emergency

contact

NameLalbiakliani Phone number+919862577575 Relation:Sister Sister Sister Sister 

Language

 Ability

Taiwanese Mandarin English Others

Speak

Read & Write

Listen

   

I wish toI wish toI wish toI wish to applyapplyapplyapply for for for for (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 (July15□17…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 Story□Telling Instruments Field of 

interest

Kids teaching leading Teenagers Community service

Environmental concerns

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.

8/7/2019 Cinnie

http://slidepdf.com/reader/full/cinnie 2/2

 

I Love Taiwan Mission 2011Health Agreement and Liability Release Form

Parents 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.

Participant’s Name: Hmar Lalhmangaihi Date of Birth: 14th August, 1982

Home Address: Dawrpui Vengthar

City: Aizawl State/County/Country: Mizoram, India Zip: 796001

E-mail Address:  cinnie_07@yahoo.co.in 

In case of emergency, notify: Lalbiakhlui Phone:  (+91)9862577575

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: Nil List any known allergies to medication: Nil 

Parental Consent:I, Siamliani (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 Lalhmangaihi should anemergency medical treatment be necessary and will make any necessary financialreimbursements.

I Hmar Lalhmangaihi the participant, am of lawful age and legally competent tosign 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 the I

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 Holder’s Name: Nil Doctor’s Name: Nil

Parent / Guardian Signature: ____________________________ Date: 29 – 04 - 2011 

Participant Signature: __________________________________ Date: 29 – 04 - 2011