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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 - 2011Name
Passport : HMAR LIANTLUANGA
Chinese CharactersGender
F
M Photo
Date of Birth 28282828 10101010 1974197419741974 Passport Number
HHHH 9353827935382793538279353827
Church PPPPresbyterianresbyterianresbyterianresbyterian
CCCChurch ofhurch ofhurch ofhurch of IIIIndiandiandiandia
OccupationSSSSELFELFELFELF
EMPLOYEDEMPLOYEDEMPLOYEDEMPLOYED
School / MajorMAMAMAMA
Address AIZAWL, MIZORAM, INDIAAIZAWL, MIZORAM, INDIAAIZAWL,
MIZORAM, INDIAAIZAWL, MIZORAM, INDIA
Tel/ Fax(T 03890389038903892329132232913223291322329132
(FEmail
[email protected]@[email protected]@gmail.com
Emergency
contact
Name:K.LALSANGPUII Phone number :
03890389038903892329132232913223291322329132 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
Brief
Introduction
of yourself
Special Need Vegetarian Allergy Others
Parent
EndorseApplicant 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.
Participants Name: HMAR LIANTLUANGA
Date of Birth : 28 10 1974
Home Address: CHHINGA VENG,
City:__Aizawl_______State/County/Country:__India Zip: 796001
E-mail Address:
[email protected]@[email protected]@gmail.com
In case of emergency, notify: K. LALSANGPUII Phone:
0389-2329132
Health Statement:
Is the participant currently under treatment for a medical
condition? Yes /NoIf yes, please
describe:________-NA-__________________________
Has the participant been under treatment for a medical condition
in the past? Yes /NoIf yes, please
describe:____-NA-________________________________List all
medications the participant is currently taking:
______-NA-_________
List any known allergies to medication:
___-NA-_______________________
Parental Consent:I,___ K. LALSANGPUII__________ (name of
parent/guardian) give permission for the ILove Taiwan Mission Camp
staff and its affiliates to act in my behalf to approveappropriate
medical treatment for my participant _HMAR LIANTLUANGA should
anemergency medical treatment be necessary and will make any
necessary financialreimbursements.
I___HMAR LIANTLUANGA the participant, am of lawful age and
legally competentto 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:
__________-NA-__________ Policy #: __-NA-
Policy Holders Name: _________-NA-___ ______ Doctors Name:
_______________
Parent / Guardian Signature: ____________________________ Date:
29 04 2011
Participant Signature: __________________________________ Date:
29 04 2011
