Montreal Bewerbungsformular2012

Application Form 2011/2012
ABOUT YOU
First name(s):
Surname:
Date of birth :
Gender : □ M
□F
Address :
Street:
- Please affix a
photo of
yourself here
(with your name
written on the
back) -
Postcode / Town:
Telephone number:
Email:
INFORMATION ABOUT YOUR SCHOOL
School name:
Montessori Zentrum Angell
Street:
Mattenstrasse 1
Postcode/Town 79100 Freiburg
Phone
+49/761/70 32 90
Fax …………….+49/761/70 32 930
E-mail…………[email protected] oder [email protected]
Suggestion/request concerning dates of exchange visit:
Freiburg – Montréal: from …./…. to …/… (day/month/___)
Montréal – Freiburg: from …./…. to …/… (day/month/____)
School Year:
Knowledge of French (how many years / qualifications / level):
Other Language Skills:
Distance from your home to school:
Method of transport used:
TRAVEL EXPERIENCE
(private / with school)
REASONS FOR APPLYING
Why would you like to take part in this exchange?
Please indicate the members of your family who will be
in the house for the duration of the Canadian pupil’s
stay:
Others living in the house (please give details) :
□ Father
□ Brothers
□ Mother □ Sisters
Ages :
Ages :
Would you accept an exchange with someone NOT of the same sex if it is the only possibility?
□ Yes □ No
What is the accommodation offered by your family?
□ House
□
□ City
□ Town
Flat
□ Other (please specify):
□ Rural
□ Farm
Would the Canadian student have his/her own room?
□ Other (please specify):
□ Yes □ No
If no, who would the Canadian student share a room with?:
Do you have any dietary requirements (eg vegetarian) ?
□ Yes
□ No
□ Yes
□ No
Do you smoke?
□ Yes
□
No
Is there anyone who smokes in your house?
□ Yes
□ Yes
□
□
No
If yes, please give details :
Do you have any health problems (including allergies) that the family
and school in Canada should know about?
If yes, please give details :
If the only exchange possible is in a family where someone smokes,
would you still be willing to accept the place?
Is it important for you to take part in religious observance?
If yes, which religion do you practice?
No
□ Yes □ No
What are your hobbies and interests, your favourite subjects at school?
ERKLÄRUNGEN / STATEMENTS
Hiermit bestätige ich, dass alle Angaben in meiner Bewerbung nach bestem Wissen und Gewissen korrekt
sind. Ich versichere, dass ich mich aktiv am Schul- und am Familienleben in Kanada beteiligen und dabei
die Regeln der Gastschule und der Gastfamilie befolgen werde.
I confirm by my signature below that all the details submitted are, to the best of my knowledge, correct. I
agree that I will fully participate in both school and home life in Canada, following all the rules in both the
school and the home.
_______________________________________
Datum
_________________________________________
Unterschrift Bewerber/in
EINVERSTÄNDNISERKLÄRUNG DER ERZIEHUNGSBERECHTIGTEN
Hiermit bestätige ich, dass ich die Bewerbung meines Sohnes/meiner Tochter gelesen habe und unterstütze
und dass ich mit seinem/ihrem Austauschaufenthalt in Kanada einverstanden bin, sollte die Bewerbung
erfolgreich sein. Ich versichere, dass ich den Austauschpartner/die Austauschpartnerin meines
Sohnes/meiner Tochter in meinem Haus bzw. meiner Wohnung aufnehmen, ihm/ihr die „Regeln des
Hauses“ in unserer Familie erläutern und sicherstellen werde, dass mein Sohn/meine Tochter die „Regeln
des Hauses“ der kanadischen Gastfamilie befolgen wird.
I confirm that I have read and fully support the application of my son / daughter and agree to his / her
exchange visit to Canada, if he / she is successful in this application. I agree to host my son’s / daughter’s
Canadian exchange partner in my home, to explain the ‚house rules’ of the family to them, and to ensure
that my son / daughter follows the ‚house rules’ of their host family in Canada.
_______________________________________
Datum
_________________________________________
Unterschrift Erziehungsberechtige/r
EINVERSTÄNDNISERKLÄRUNG DER SCHULLEITUNG
Hiermit bestätige ich, dass ich die Bewerbung des Schülers/der Schülerin _____________________ von
unserer Schule gelesen habe und unterstütze und dass ich mit seinem/ihrem Austauschaufenthalt in Kanada
einverstanden bin, sollte die Bewerbung erfolgreich sein. Ich versichere, dass unsere Schule den
kanadischen Austauschpartner/die kanadische Austauschpartnerin während des Gegenbesuchs in
Deutschland aufnehmen und unterstützen wird.
Als Betreuungslehrer/in für diesen Austausch
(s. Programmbeschreibung) wird an unserer Schule benannt: __________________________________
I confirm that I have read and fully support the application of my student ____________________ and
agree to his / her visit to Canada, if he / she is successful in this application. I agree that our school will
host a Canadian student on a reciprocal visit, and fully support them during their visit.
The mentor teacher at our school for this exchange will be: _____________________________________
_______________________________________
Datum
_________________________________________
Unterschrift Schulleitung