The 2nd

R.O.C.

Asia 4-H Network Conference, Taiwan,

Recent Photo

(Nov. 27 Dec.3, 2016)

PARTICIPANT FORM

This
participant
H Network
and give

information Form is to be completed by

who is going to participate in the 2nd Asia 4Conference. Please type in block letter,
complete and detailed information.

Home

Country:

Flight Schedule:
Arrival date, time and flight no.
Departure date, time and flight no.
(Note: Free bus services is available only on Nov. 27, 2016 from Taiwan Taoyuan
International Airport to Mellow Fields Hotel in Taipei, and is also available only on
Dec. 3, 2016 from Mellow Fields Hotel to Taiwan Taoyuan International Airport)
PERSONAL DETAILS:
Family name:

First name:

Date of birth (DD/MM/YY):

E-Mail:

Gender: Male ( ) Female (

Mobile phone:

Telephone no.

Fax no.

Mailing Address:
Place of residence: City, Town, Rural, Farm
Person to contact in case of emergency:

Telephone no.

Mobile phone:
Religion:
( ) Christianity, ( ) Catholicism, ( ) Muslim, ( ) Buddhism, ( ) Hinduism,
( ) Sikhism,

( ) other:

Education:
(

) Graduated school,

) University or College, (

4-H:
(

) Agent, (

) Member, (

) Volunteer
1

) High school

Languages:
Very good
English

Chinese

Good

Fair

Little

Other information (Food you cannot eat or allergies, vegetarian, meat and
vegetable dish, etc.)

.
Insurance: Every participant is responsible for her/his own insurance.
I do have an insurance policy for this conference.
Signature:

Date:

Participant fee: (

) US $300 per person (from Nov. 27 to Dec. 3,

2016 ), or
(

) US $150 per person (from Nov. 27 to Nov. 29, 2016)

Please make remittance to:

A/C WITH BANK: CATHAY UNITED BANK, TAIPEI, TAIWAN.

SWIFT CODE:

UWCBTWTP
BENEFICIARYS NAME: NATIONAL 4-H CLUB ASSOCIATION, R.O.C. ACCOUNT NO.
030087085755
Note: After fill in the form, please email it no later than September 10, 2016 to:
Miss Sophie Chen, National 4-H club Association, at E-mail:
82812sspp@fourh.org.tw
The following information is only for Country organizer to fill in:
4-H Exhibitions Display List (Please list the things you like to display in 4-H
Exhibition (for a 180cm 60cm table), and please prepare at least two
questions for the Challenge Activity):

4-H Night (10 minutes Cultural show for each country)

( ) We will perform in 4-H Night, the show is:
( ) We will not perform in 4-H Night.