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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

PassportFanai Lalhmuzuali

Chinese CharactersGender

F

M Photo

Date of Birth 25252525thththth May 1980May 1980May 1980May 1980 Passport Number H. 93538H. 93538H. 93538H. 9353838383838

Church P.C.IP.C.IP.C.IP.C.I Occupation Self employedSelf employedSelf employedSelf employed

School / MajorM.AM.AM.AM.A

Address AizawlAizawlAizawlAizawl ,,,,MizoramMizoramMizoramMizoram ,,,,IndiaIndiaIndiaIndia

Tel/ Fax(T91919191 98231959982319599823195998231959

(F

Email

Emergency

contact

NameF.F.F.F.

RamchangRamchangRamchangRamchanglianalianalianaliana

Phone number91919191 9825788982578898257889825788 Relation:FatherFatherFatherFather

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 (July1517Have you ever particiHave you ever particiHave you ever particiHave you ever participated in ILT?pated in ILT?pated in ILT?pated 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

BriefIntroduction

of yourself

I am a good looking and happy man. I love music and playing basketballI am a good looking and happy man. I love music and playing basketballI am a good looking and happy man. I love music and playing basketballI am a good looking and happy man. I love music and playing basketball

Special Need Vegetarian Allergy Others

Parent

EndorseApplicant 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 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: Fanai Lalhmuzuali Date of Birth:25th May 1980

Home Address: Tuithiang, Aizawl

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

E-mail Address:

In case of emergency, notify: F. Ramchangliana Phone: (_91 )9862578686

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,F. Ramchangliana (name of parent/guardian) give permission for the I Love TaiwanMission Camp staff and its affiliates to act in my behalf to approve appropriate medicaltreatment for my son/daughter/participant Fanai Lalhmuzuali should an emergencymedical treatment be necessary and will make any necessary financial reimbursements.

I Fanai Lalhmuzuali participant, am of lawful age and legally competent to sign thisMedical 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 #: __________________

Policy Holders Name: Nil Doctors Name: _______________

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

Participant Signature: __________________________________ Date: 29 04 - 2011