Application form for the C3 Mobility in Romania

School George Emil Palade Buzau

20-26 May 2019
STEAM like Leonardo - KA229 project

Please write all information clearly in blue

Remember: Photo
It’s important to be accurate when filling in it in order to get
a suitable partner

Surname/s First name

Home address (incl. postcode )

Parents’
Mobile (00)
mobile

Email address

Facebook

Do you wish to be contacted by WhatsApp?

Gender
Citizenship
(male/female)

Date of birth / / Age

Year level at school

Full name of father Occupation

1
Full name of mother Occupation

Foreign languages spoken in the family:

Preferred exchange partner: boy / girl / either boy or girl

The following adjectives describe me:

quiet, reserved athletic artistic, musical shy humorous
outgoing relaxed academic sociable adaptable, flexible

Hobbies & Interests

Hobbies practised :

I am interested in:

I am not interested in:

Musical instruments that I play:

Favourite music

Favourite book/s

Favourite film/s

What do you prefer doing in the afternoon and in the evening after school?

What do you prefer doing at the weekends?

Are you a member of any youth organisation? (Name it)

Have you got pets?

Do you suffer from any physical disabilities or allergies? Yes No
If „Yes“ above, please give details

Do you receive any medical treatment?

2
If „Yes“ above, please give details

Have you got any food

intolerance?

Are you a vegetarian/vegan?

Name any countries you have visited (when, where, how long, exchange?)

Accommodation

House / flat / rural cottage / …

How far is your home from the school?

How do you go to school?

Will the partner have his/her own room? Yes / No

Family members (at home including you):

Father (yes/No) 
Mother (yes/No) 
sisters?  age

brothers?  age

others? 

I am a non-smoker / smoker
Are there smokers in my home? (Number please)
Can you accept a placement in a home with smokers? (yes/no)

Would my family accept a smoker? (yes/no)

Do you have any particular requests?

3
 Please write a half-page description of yourself, your family, your interests and social
activities, any ideas you may have about your future, and give reasons for wishing to
participate in the mobility. It is going to be a motivation letter to participate in the
mobility. You should also write the URL of a video about yourself with the information
about yourself:
URL video: