Erasmus+ project participant to C2 photo

Personal information

First name: ………………………………………………..

Family name: ……………………………………………..

Address:……………………………………………………

Telephone (including country code):

…………………………………………………

A PARENT phone no (including country code):

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Email address:…………………………………………

Birthday:…………………………………………………...

Medical requirements/Health restrictions and dietary requirements:

Do you have any physical restrictions/allergies that will limit placement option or participation in
everyday family and/or school activities?

Yes ……. No …….. if yes, please explain:

………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………

I cannot live in a home with: cats dogs other pets:

Are you a vegetarian? Yes No

If yes are you willing to eat: fish dairy products poultry pork

Do you have dietary restrictions? Yes No if yes, please explain:

………………………………………………………………………………………………………………………………………………………

Hobbies and leisure activities:

Sports practiced: ………………………………………………………………………………………………..

Leisure activities practiced (music/Art, etc.) ……………………………………………………….

Other interests: …………………………………………………………………………………………………..

How do you spend your free time afternoons and weekends?

………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

I am best described as:

calm/reserved energetic/outgoing socially active

shy academic athletic friendly/easy to get along

Family data:

Brothers and sisters living at home (name and age)

1) sisters ……………………………………………………………………………………………………………..………..

2) brothers ………………………………………………………………………………………………………………….