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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
PassportJohn Lalremruata
Chinese CharactersGender
F M
Photo
Date of Birth 22222222ndndndnd March, 1983March, 1983March,
1983March, 1983 Passport Number H. 9373834H. 9373834H. 9373834H.
9373834
Church PCIPCIPCIPCI Occupation
BusinessBusinessBusinessBusiness
School / MajorB.AB.AB.AB.A
Address Aizawl, Mizoram, IndiaAizawl, Mizoram, IndiaAizawl,
Mizoram, IndiaAizawl, Mizoram, India
Tel/ Fax(T +91919191 912904839912904839912904839912904839
(FEmail
[email protected]@[email protected]@yahoo.in
Emergency
contact
NameLalfakzuala Phone number+919436352300 Relation:
BrotherBrotherBrotherBrother
inininin lawlawlawlaw
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
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
I m interested in learning new things. II m interested in
learning new things. II m interested in learning new things. II m
interested in learning new things. I m very fond of music and
playing musicalm very fond of music and playing musicalm very fond
of music and playing musicalm very fond of music and playing
musical
instrumentsinstrumentsinstrumentsinstruments
Special Need Vegetarian Allergy Others
Parent
Endorse
Applicant 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: John Lalremruata Date of Birth:
22222222ndndndnd March, 1983March, 1983March, 1983March, 1983
Home Address: V-32, Salem Veng
City: Aizawl State/County/Country: Mizoram, India Zip:
796001
E-mail Address:
[email protected]@[email protected]@yahoo.in
In case of emergency, notify: Lalfakzuala Phone:
(+91)9436352300
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: NilList any
known allergies to medication: Nil
Parental Consent:I, Ralthuami (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
treatment
for my son/daughter/participant John Lalremruata should an
emergency medicaltreatment be necessary and will make any necessary
financial reimbursements.
I John Lalremruata the 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 I
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: Nil Policy #:
Nil
Policy Holders Name: Nil Doctors Name: Nil
Parent / Guardian Signature: ____________________________ Date:
29 04 - 2011
Participant Signature: __________________________________ Date:
29 04 - 2011
