Jacob

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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 Name Date of Birth Church Passport Jacob Lalrohnuna Chinese Characters 01st Oct 1979 P.C.I Date Gender F M 29 – 04 - 2011 Photo

Passport Number H. 9353835
Occupation

Business

School / Major B.A Aizawl ,Mizoram ,India Address (T…91□ 98:23118:0 91□ 91 Email [email protected] (F… Emergency Name Chawngthu Phone number 91□ 98:2382374 91□ Relation:Wife Wife contact Lalremruati Taiwanese Mandarin English Others Speak Language Read & Write Ability Listen Tel/ Fax I wish to apply for (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 (July15□17… Have you ever participated in ILT? If yes, please note which year and attend which church in Taiwan. No Yes, , church Special Skills Field of interest Music Computer Drama Story□Telling Art Instruments Community service leading Teenagers

Kids teaching Environmental concerns

Brief Introduction of yourself

Special Need Parent Endorse Local Church Endorse

Vegetarian

Allergy

Others Applicant Sign

Please fill it out and send back to your denomination contact person.

I Love Taiwan Mission 2011
Health Agreement and Liability Release Form
Parents and Participants: This form is MANDATORY for participation. Please read it carefully and sign where indicated. Participants’ over 18 years of age do not require parental consent but we still need this completed form on file. Participant’s Name:Jacob Lalrohnuna Date of Birth:1st oct 1979 Home Address: Bungkawn, Aizawl City:Aizawl State/County/Country: Mizoram, India Zip: 796001

E-mail Address: [email protected] In case of emergency, notify:C.Lalremruati Phone: (_91 )9862382374 Health Statement: Is the participant currently under treatment for a medical condition? Yes / No If yes, please describe:____________________________________________________ Has the participant been under treatment for a medical condition in the past? Yes / No If yes, please describe:____________________________________________________ List all medications the participant is currently taking: ____________________________ List any known allergies to medication: _______________________________________ Parental Consent: I,Lalrawnthanga (name of parent/guardian) give permission for the I Love Taiwan Mission Camp staff and its affiliates to act in my behalf to approve appropriate medical treatment for my son/daughter/participant Jacob Lalrohnuna should an emergency medical treatment be necessary and will make any necessary financial reimbursements. I Jacob Lalrohnuna participant, am of lawful age and legally competent to sign this Medical Release. I understand that the terms herein are contractual and are not a mere recital; and that I have 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 made pursuant to their authorization. I have fully informed myself of the contents of the Medical Release by reading it and that the medical and insurance information I give below is accurate. Health Insurance Carrier: Nil Policy Holder’s Name: Nil Policy #: __________________ Doctor’s Name: _______________

Parent / Guardian Signature: ____________________________ Date: 29 – 04 - 2011 Participant Signature: __________________________________ Date: 29 – 04 - 2011

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