PUPIL INFORMATION FORM

1. Name and address of the pupil

First name:
Last name:
Telephone:
Mobile phone:

Street:

Denis

Postal code & city:

Metrovi

Email address:

+38513862237

Radgonska 49
10090, Zagreb
denisivan@windowsliv
e.com

Date of birth:

+385919062614

23.10.1998.

2. Family data
I live with:

Mother and father

Mother and partner
Father and partner
Mother
Father
Other (explain):

Mother/Guardian
First name:
Last name:
Occupation:

Mobile phone:

Gordana

Daytime phone:

Metrovi

+385915975124
+385912459218

Deputy store
manager

Father/Guardian
First name:
Last name:
Occupation:

Mobile phone:

eljko

+385919291629

Daytime phone:

Metrovi

Salesman

Brothers and sisters

Name

Nina

Gende
r
Femal
e

Age

11

Living at
home?

Yes

No

3. Placement information
Do you have any disabilities (physical restrictions, impairments) or allergies that will
limit placement options or participation in everyday family and/or school activities?
Yes
No
If yes, please explain and specify if any aids, adaptations or special assistance will be
required:

I CANNOT live with:

cats
dogs
other pets:
Do you have dietary restrictions, e.g. for medical, religious or other self-imposed
reasons?
Yes
No
If yes, please explain:

If you are a vegetarian, are you willing to eat:

Fish
Poultry
Dairy products
Do you smoke?
Yes
No
Must you be hosted in a non-smoking home?
Yes
No

Are there any other aspects that need to be considered in order to select a suitable
host family?
Yes
No
If yes, please explain:

4. Languages
Mother tongue:

Croatian

Other languages:
Years studied
Poor
1
2

English

German

Speaking ability
Fair
Good

Excellent

11

5. For visa and travel purposes

City of birth:

Zagreb

Country of birth:

Republic of Croatia

Date of birth:

23.10.1998.

Nationality:

Croatian

Passport / ID:
Number:

201123260

Issue date:

10.6.2015.

Place of issue:

PU/Zagreb

Expiration date:

10.6.2020.

* Please attach a copy of the Passport/ID to the Form

6. Signatures
I, the undersigned, allow the Project Coordinator (Fondazione Eni Enrico Mattei) and
the sending school to use the data included in this form for the purposes of mobility
within the framework of the Erasmus+ programme. I agree that these data will be
communicated to the receiving school and to the family which will host my child. I
understand that the data contained in this form may also be communicated to the

sending and receiving National Agencies in charge of the Erasmus+ programme. All
the people receiving these data will be required to treat them as confidential.
Agreed and accepted by
Name(s) of Parent(s)/Guardian(s)
Gordana Metrovi
eljko Metrovi
Signature(s) of Parent(s)/Guardian(s)

Date

Name of pupil
Denis Metrovi
Signature of pupil

Date