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PUPIL INFORMATION FORM

1. Name and address of the pupil

First name:Denis

Street:Radgonska 49

Last name:Metroi!

"ostal #ode $ #it%:1&&9&' (agre)

*elephone:+,-1,-/00,

2mail address: denisian3indoslie.#om

Mo)ile phone:+,-919&/0/14

Date of )irth:0,.1&.199-.

0. Famil% data

5 lie ith:

Mother and father Mother and partner Father and partner Mother Father 6ther 7e8plain:

Mother;uardian

First name:;ordana

Mo)ile phone:+,-919104

Last name:Metroi!

Da%time phone:+,-9104901-

6##upation: Deput% storemanager

Father;uardian

First name:rothers and sisters

Name ;ender

?ge @es No

Nina Female

11Liing athomeA

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,. "la#ement information

Do %ou hae an% disa)ilities 7ph%si#al restri#tions' impairments or allergies that illlimit pla#ement options or parti#ipation in eer%da% famil% andor s#hool a#tiitiesA

@es No

5f %es' please e8plain and spe#if% if an% aids' adaptations or spe#ial assistan#e ill )ereBuired:

5 C?NN6* lie ith:

#ats dogs other pets:

Do %ou hae dietar% restri#tions' e.g. for medi#al' religious or other selfimposedreasonsA

@es No

5f %es' please e8plain:

5f %ou are a egetarian' are %ou illing to eat:

Fish "oultr% Dair% produ#ts

Do %ou smokeA

@es No

Must %ou )e hosted in a nonsmoking homeA

@es No

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?re there an% other aspe#ts that need to )e #onsidered in order to sele#t a suita)lehost famil%A

@es No

5f %es' please e8plain:

4. Languages

Mother tongue: Croatian

6ther languages:

@ears studied Speaking a)ilit%"oor Fair ;ood 28#ellent

12nglish

11

0;erman

9

,

. For isa and trael purposes

Cit% of )irth: (agre) Countr% of )irth: Repu)li# of Croatia

Date of )irth: 0,.1&.199-. Nationalit%: Croatian

Passport / ID:

Num)er: 0&110,0/& 5ssue date: 1&./.0&1.

"la#e of issue: "E(agre) 28piration date: 1&./.0&0&.

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

/. Signatures

5' the undersigned' allo the "ro=e#t Coordinator 7Fondaione 2ni 2nri#o Mattei andthe sending s#hool to use the data in#luded in this form for the purposes of mo)ilit%

ithin the frameork of the 2rasmus+ programme. 5 agree that these data ill )e#ommuni#ated to the re#eiing s#hool and to the famil% hi#h ill host m% #hild. 5understand that the data #ontained in this form ma% also )e #ommuni#ated to the

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sending and re#eiing National ?gen#ies in #harge of the 2rasmus+ programme. ?llthe people re#eiing these data ill )e reBuired to treat them as #onGdential.

?greed and a##epted )%

Name7s of "arent7s;uardian7s

;ordana Metroi!