YEAR 2015-2016
APPLICATION FORM
To be completedand handed in with the request
for an exchange in S5 before7 January 2016,
for an exchange in S4 before 4 April 2016?
- ABOUT THE STUDENT
Surname /
First name
Date of birth
Place of birth
Sex / M F
Nationality / 1………………..……………. 2. ………………………………………
Main language of the student
Europeanschool of origin / Bruxelles II
Class…………………... / Section ………………………………………..
LI ……………….…. LII…………….……. LIII……………...………
MATHS: 4 6
Selected options:
Other activities at school (music, sports…):
Desired period of exchange from: ………/………/………….…. to ………/………/…………..……..
Our family is prepared to receive a student from a European school: yes no
- MEDICAL INFORMATION FORM
Does the child suffer any chronic or recurrent diseases? yes no
Please specify………………………………………………………………
Does he have asthma? : yes no
Does he suffer epilepsy? : yes no
Does he have diabetes? : yes no
Any food allergies (peanut, kiwi, strawberry)?: yes no
Please specify:…………………………………………………………….
Your child is allergic to penicillin? : yes no
Other:
……………………………………………………………………………………………………...…………………..……………………………………………………………………………………………………………..……………………
Person to contact in case of emergency:
……………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………
- ABOUT THE HOST FAMILY (if already known)
Names of the parents of the host family:…………………………………………………………………………………
Street:……………………………………………………………Nº….…… Box/Floor:..…….………...... …
Post code:...….…..…Town/City:…………………………… Country:…………..…………………………………..….
Phone number:…………………..……...… GSM:……………………………………………………
E-mail:…………………………………………………………………………………………..……………………………
- ABOUT THE STUDENT’S MOTHER
Surname: ………………………………………………First name : ……………………………………………
Nationality: ……………………..…. Main language: ………………………………………….
Work phone number: ……………………… Tel/GSM: ………………………………..…….………...
E-mail: ……………………………………………………………..…………………………………..……………………
Address: Street:…………………………… Nº….…… Box/Floor: ..…….……
Post code:...….……..…..City:………………………………..
Country:…………..…………
- ABOUT THE STUDENT’S FATHER
Surname: ………………………………………………First name : ……………………………………………
Nationality: ……………………..…. Main language: ………………………………………….
Work phone number: ……………………… Tel/GSM: ………………………………..…….………...
E-mail: ……………………………………………………………..…………………………………..……………………
Address: Street:…………………………… Nº….…… Box/Floor: ..…….……
Post code:...….……..…..City:………………………………..
Country:…………..…………
6. DOCUMENTS TO BE ATTACHED
School reports showing results from the last semester:
7. PARENTS’ DECLARATION
I undertake to respect the General Rules of the European Schools as well as thedocument 2014-04-D-9-en “Guidelines on organizing student exchanges in the European Schools”.
I, the undersigned hereby confirm the accuracy of the information provided on this form and agree to report any changes in the information submitted so far.
Signature of the mother:Date:
Signature of the father: Date: