dr_samuela
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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
PassportSamuel Vanlalthlanga
Chinese CharactersGender
F
M Photo
Date of Birth 13131313thththth Jan 1973Jan 1973Jan 1973Jan 1973 Passport Number H. 93538H. 93538H. 93538H. 9353824242424
Church P.C.IP.C.IP.C.IP.C.I Occupation LecturerLecturerLecturerLecturer
School / MajorPPPPhhhh....DDDD
Address AizawlAizawlAizawlAizawl ,,,,MizoramMizoramMizoramMizoram ,,,,IndiaIndiaIndiaIndia
Tel/ Fax(T91919191 03890389038903892330821233082123308212330821
(FEmail [email protected]@[email protected]@yahoo.co.in
Emergency
contact
Name
LalngaihmanawmiLalngaihmanawmiLalngaihmanawmiLalngaihmanawmi
Phone number91919191 03890389038903892330821233082123308212330821 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 youHave youHave youHave you ever participated in ILT?ever participated in ILT?ever participated in ILT?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
Endorse Applicant Sign
Local Church
Endorse
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Please fill it out and send back to your denomination contact person.
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:Samuel Vanlalthlanga Date of Birth:13th Jan 1973
Home Address: A-163, luangmual, Aizawl, Mizoram
City:Aizawl State/County/Country: Mizoram, India Zip: 796001
E-mail Address: [email protected]@[email protected]@yahoo.co.in
In case of emergency, notify:C.Lalremruati Phone: (_91 )9862382374
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,Lalramliana (name of parent/guardian) give permission for the I Love Taiwan MissionCamp staff and its affiliates to act in my behalf to approve appropriate medical treatmentfor my son/daughter/participant Samuel Vanlalthlanga should an emergency medicaltreatment be necessary and will make any necessary financial reimbursements.
I Samuel Vanlalthlanga participant, am of lawful age and legally competent to signthis 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 #: __________________
Policy Holders Name: Nil Doctors Name: _______________
Parent / Guardian Signature: ____________________________ Date: 29 04 - 2011
Participant Signature: __________________________________ Date: 29 04 - 2011