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INDIVIDUAL INFORMATION FORM fiche de renseignements individuelle School Lycée Louis Pasteur 13 rue pont de Trouca 84000 Avignon France School to be visited: Mount Douglas Secondary School, 3970 Gordon Head Road V8N 3X3 Victoria, BC, CANADA Veuillez remplir cette fiche en utilisant des caractères gras. Nous vous demandons de renseigner très précisément les parties sur les allergies, les problèmes éventuels concernant l’alimentation et la santé. photo d’identité Family name / nom de famille de l’élève : Mr. , Mrs. , Miss, Ms.* ..................................... First name / prénom : ........................................................................................................... Gender/sexe Age: ...................... Birthdate/ date de naissance: ........................................ (day, month, year) citizenship / nationalité : ....................................................... Address : .............................................................................................................................. .............................................................................................................................................. City / commune ................................................................................................................... Postal code ................................ Telephone # ( home / domicile ) .............................................. ( work / travail ) .................................................... parents’ e-mail address: .............................................................................. student’s e-mail address: .............................................................................. INFORMATION FOR HOST FAMILY SELECTION / renseignements pour le choix de la famille d’accueil I must be twinned with a person of the same sex Je veux être logé chez qqu’un du même sexe que moi YES NO I want to stay with (write the name) / Je veux être logé chez : ……………………………… ANIMALS I can go to a home where there are animals je peux loger dans une famille où il y a des animaux YES NO I am allergic to some animals, say which ( je suis allergique à des animaux, dites lesquels) ………………………………………………………………………………………………… ………………………………………………………………………………………………… ● I’m fine if I don’t touch the animal YES NO Je n’ai pas de problème si je ne touche pas l’animal ● I’m fine if the animal doesn’t come into my room YES NO Je n’ai pas de problème si l’animal ne vient pas dans ma chambre ● I must be in a house where they don’t have this animal YES NO Je dois loger dans une maison où il n’y a pas cet animal DIET I have some limitations in diet (je suis un régime) YES NO Indicate which ones/ indiquez lesquelles ……………………………………………………………………………………… ……………………………………………………………………………………… I am allergic to some food/je suis allergique à certains aliments YES NO Indicate which ones/indiquez lesquels ……………………………………………………………………………………… ……………………………………………………………………………………… SMOKING I smoke/ Je fume YES NO I can go to a home where someone smokes at home je peux loger dans une famille où il y a des fumeurs YES NO HEALTH Please describe any limitations in physical activity/ indiquez si certaines activités sportives vous sont déconseillées...... ………………………………………………………………………………………………… ………………………………………………………………………………………………… Please describe any special medical requirements which should be known to the host family / indiquez tout renseignement médical vous concernant que la famille d’accueil doit connaître ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… EXPERIENCE with trips and exchange programmes What trips to foreign countries have you undertaken in past years? / voyages effectués à l’étranger : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Do you have past experience with group tours or exchange programmes? / Avez-vous déjà participé à un voyage en groupe ou à un échange? ………………………………………………………………………………………………… Please elaborate / donnez des précisions ………………………………………………………………………………………………… ………………………………………………………………………………………………… Is your knowledge of the language of the country which you are visiting Vous parlez la langue du pays * fluent/couramment good/bien adequate for general conversation/suffisante pour la conversation courante slight/insuffisante none/pas du tout * circle the suitable answer/entourez la réponse appropriée Interests and hobbies What hobbies do you have? ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… What sports do you play regularly? ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Are you a member of any clubs or associations? YES NO Please elaborate/ donnez des précisions ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… What music do you enjoy listening to? ………………………………………………………………………………………………… ………………………………………………………………………………………………… I like to spend time with my friends a lot quite a bit (pas mal) not much never I like to spend time on my own J’aime passer du temps seul a lot quite a bit (pas mal) not much never I like to read a lot quite a bit (pas mal) not much never I like to watch TV a lot quite a bit (pas mal) not much never I like to spend time playing video games a lot quite a bit not much never I like to spend time on the computer a lot quite a bit not much never I like to be busy all the time I enjoy team sports I enjoy individual sports most of the time YES YES a little NO NO Nom du père ________________________ Nom de la mère ____________________ adresse _____________________________ ___________________________________ adresse ___________________________ _________________________________ Tel # ___________________________ Tel # ____________________________ portable ___________________________ portable __________________________ Who should be contacted in case of emergency? / personnes à contacter en cas d’urgence : Principal contact Alternate contact/autre personne Name/nom __________________________ address _____________________________ ___________________________________ Tel # ___________________________ Name/nom ________________________ address ___________________________ _________________________________ Tel # ____________________________
