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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 Date 29 – 04 - 2011

NamePassport Sailo VanlaldinglianiChinese Characters

Gender F

M

Photo

Date of Birth 28282828 thththth October, 1977October, 1977October, 1977October, 1977 Passport Number H. 9353837H. 9353837H. 9353837H. 9353837

Church PCIPCIPCIPCI Occupation BusinessBusinessBusinessBusiness

School / Major M.AM.AM.AM.A

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

Tel/ Fax(T… +91919191 943 3 178943 3 178943 3 178943 3 178(F…

Email

Emergencycontact

Name S. Lianchhuma Phone number +91 9436191721 Relation: FaFaFaFather ther ther ther

Language Ability

Taiwanese Mandarin English OthersSpeakRead & WriteListen

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 par Have you ever par Have you ever par Have you ever participated in ILT?ticipated in ILT?ticipated in ILT?ticipated 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 Introductionof yourself

Special Need Vegetarian Allergy Others

Parent

Endorse Applicant Sign

Local ChurchEndorse

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 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: Sailo Vanlaldingliani Date of Birth: 28282828 thththth October, 1977October, 1977October, 1977October, 1977

Home Address: H/No V-II-5 I.T.I Veng

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

E-mail Address: ____ ____ ____ ______________________________________ __________________________________ __________________________________ _______________________________________________________ _____________________ _____________________ _____________________

In case of emergency, notify: S.Lianchhuma Phone: (+91)9436191721

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, S.Lianchhuma (name of parent/guardian) give permission for the I LoveTaiwan Mission Camp staff and its affiliates to act in my behalf to approve appropriatemedical treatment for my son/ daughter /participant Sailo Vanlaldingliani should anemergency medical treatment be necessary and will make any necessary financialreimbursements.

I Sailo Vanlaldingliani 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 ILove 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