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  • Cinnie

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    Muanchhana Mizo
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    This document is an application form and medical release for I Love Taiwan Mission 2011. It contains personal information about the applicant such as name, date of birth, passport information, contact details, emergency contact, languages spoken, interests and skills. It also includes a health statement, list of medications, known allergies, parental consent for medical treatment if needed, and insurance information. The applicant and parent/guardian sign to acknowledge the terms of the medical release.

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    This document is an application form and medical release for I Love Taiwan Mission 2011. It contains personal information about the applicant such as name, date of birth, passport information, contact details, emergency contact, languages spoken, interests and skills. It also includes a health statement, list of medications, known allergies, parental consent for medical treatment if needed, and insurance information. The applicant and parent/guardian sign to acknowledge the terms of the medical release.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    33 views2 pages

    Cinnie

    Uploaded by

    Muanchhana Mizo
    This document is an application form and medical release for I Love Taiwan Mission 2011. It contains personal information about the applicant such as name, date of birth, passport information, contact details, emergency contact, languages spoken, interests and skills. It also includes a health statement, list of medications, known allergies, parental consent for medical treatment if needed, and insurance information. The applicant and parent/guardian sign to acknowledge the terms of the medical release.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 2

    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 - 2011
    Passport Hmar Lalhmangaihi F
    Name Gender Photo
    Chinese Characters M
    Date of Birth 14th August, 1982 Passport Number G. 1750302

    Church PCI Occupation Self Employed


    School / Major Master of Social Work (MSW…
    Address Aizawl, Mizoram, India
    (T… +91
    91 985：927117
    Tel/ Fax Email [email protected]
    (F…
    Emergency Name Lalbiakliani Phone number +919862577575 Relation:Sister
    Sister
    contact
    Taiwanese Mandarin English Others
    Speak 
    Sprache
    Read & Write
    Ability 
    Listen
    
    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
     Music Drama Art
    Special Skills
    Computer Story□Telling Instruments
    Field of  Kids teaching leading Teenagers Community service
    interest Environmental concerns

    Brief
    Introduction
    of yourself

    Special Need Vegetarian Allergy Others


    Parent
    Applicant Sign
    Endorse
    Local Church
    Endorse
    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: Hmar Lalhmangaihi Date of Birth: 14th August, 1982

    Home Address: Dawrpui Vengthar

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

    E-mail Address: [email protected]

    In case of emergency, notify: Lalbiakhlui Phone: (+91)9862577575

    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: Nil
    List any known allergies to medication: Nil

    Parental Consent:
    I, Siamliani (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 Hmar Lalhmangaihi should an
    emergency medical treatment be necessary and will make any necessary financial
    reimbursements.

    I Hmar Lalhmangaihi the 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 #: Nil

    Policy Holder’s Name: Nil Doctor’s Name: Nil

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

    Participant Signature: __________________________________ Date: 29 – 04 - 2011

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