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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
PassportVanlalhruaii
Chinese CharactersGender
F
M Photo
Date of Birth 15151515thththth March 1981March 1981March
1981March 1981 Passport Number H. 93538H. 93538H. 93538H.
9353831313131
Church P.C.IP.C.IP.C.IP.C.I Occupation Self employedSelf
employedSelf employedSelf employed
School / MajorB.scB.scB.scB.sc
Address AizawlAizawlAizawlAizawl
,,,,MizoramMizoramMizoramMizoram ,,,,IndiaIndiaIndiaIndia
Tel/ Fax(T91919191 98230032982300329823003298230032
(F
Email
[email protected]@[email protected]@gmail.com
Emergency
contact
NameKhawlhringKhawlhringKhawlhringKhawlhring
DarthangaDarthangaDarthangaDarthanga
Phone number91919191 943155898943155898943155898943155898
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
yHave yHave yHave you ever participated in ILT?ou ever participated
in ILT?ou ever participated in ILT?ou 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
BriefIntroduction
of yourself
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:Vanlalhruaii Date of Birth:15th March 1981
Home Address: B/75, Republic Vengthlang, Aizawl, Mizoram
City:Aizawl State/County/Country: Mizoram, India Zip: 796001
E-mail Address:
[email protected]@[email protected]@gmail.com
In case of emergency, notify:Khawlhring Darthanga Phone: (_91
)9436155898
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,khawlhring Darthanga (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
Vanlalhruaii should an emergencymedical treatment be necessary and
will make any necessary financial reimbursements.
I Vanlalhruaii participant, am of lawful age and legally
competent to sign this MedicalRelease.
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
made
pursuant 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
