Application Form ABOUT YOU INFORMATION ABOUT YOUR SCHOOL. - Please affix a photo of yourself here (with your name written on the back) -

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1 Application Form ABOUT YOU First name(s): Surname: Date of birth : Gender : M F Address : Street: Postcode / Town: Telephone number: - Please affix a photo of yourself here (with your name written on the back) - INFORMATION ABOUT YOUR SCHOOL School name: Rotteck-Gymnasium Street: Lessingstr. 16 Postcode/Town Freiburg Phone +49/761/ Fax.+49/761/ Suggestion/request concerning dates of exchange visit: Freiburg Montréal: from./. to / (day/month/ ) Montréal Freiburg: from./. to / (day/month/ ) School Year: Knowledge of French (how many years / qualifications / level): Other Language Skills:

2 Distance from your home to school: Method of transport used: TRAVEL EXPERIENCE (private / with school) REASONS FOR APPLYING Why would you like to take part in this exchange?

3 Please indicate the members of your family who will be in the house for the duration of the Canadian pupil s stay: Others living in the house (please give details) : Father Brothers Ages : Mother Sisters Ages : Would you accept an exchange with someone NOT of the same sex if it is the only possibility? Yes No What is the accommodation offered by your family? House Flat Other (please specify): City Town Rural Farm Other (please specify): Would the Canadian student have his/her own room? Yes No If no, who would the Canadian student share a room with?: Do you have any dietary requirements (eg vegetarian)? Yes No If yes, please give details : Do you have any health problems (including allergies) that the family and school in Canada should know about? If yes, please give details : Yes No Do you smoke? Yes No Is there anyone who smokes in your house? Yes No If the only exchange possible is in a family where someone smokes, would you still be willing to accept the place? Yes No Is it important for you to take part in religious observance? Yes No If yes, which religion do you practice?

4 What are your hobbies and interests, your favourite subjects at school?

5 ERKLÄRUNGEN / STATEMENTS Hiermit bestätige ich, dass alle Angaben in meiner Bewerbung nach bestem Wissen und Gewissen korrekt sind. Ich versichere, dass ich mich aktiv am Schul- und am Familienleben in Kanada beteiligen und dabei die Regeln der Gastschule und der Gastfamilie befolgen werde. I confirm by my signature below that all the details submitted are, to the best of my knowledge, correct. I agree that I will fully participate in both school and home life in Canada, following all the rules in both the school and the home. Unterschrift Bewerber/in EINVERSTÄNDNISERKLÄRUNG DER ERZIEHUNGSBERECHTIGTEN Hiermit bestätige ich, dass ich die Bewerbung meines Sohnes/meiner Tochter gelesen habe und unterstütze und dass ich mit seinem/ihrem Austauschaufenthalt in Kanada einverstanden bin, sollte die Bewerbung erfolgreich sein. Ich versichere, dass ich den Austauschpartner/die Austauschpartnerin meines Sohnes/meiner Tochter in meinem Haus bzw. meiner Wohnung aufnehmen, ihm/ihr die Regeln des Hauses in unserer Familie erläutern und sicherstellen werde, dass mein Sohn/meine Tochter die Regeln des Hauses der kanadischen Gastfamilie befolgen wird. I confirm that I have read and fully support the application of my son / daughter and agree to his / her exchange visit to Canada, if he / she is successful in this application. I agree to host my son s / daughter s Canadian exchange partner in my home, to explain the house rules of the family to them, and to ensure that my son / daughter follows the house rules of their host family in Canada. Unterschrift Erziehungsberechtige/r EINVERSTÄNDNISERKLÄRUNG DER SCHULLEITUNG Hiermit bestätige ich, dass ich die Bewerbung des Schülers/der Schülerin von unserer Schule gelesen habe und unterstütze und dass ich mit seinem/ihrem Austauschaufenthalt in Kanada einverstanden bin, sollte die Bewerbung erfolgreich sein. Ich versichere, dass unsere Schule den kanadischen Austauschpartner/die kanadische Austauschpartnerin während des Gegenbesuchs in Deutschland aufnehmen und unterstützen wird. Als Betreuungslehrer/in für diesen Austausch (s. Programmbeschreibung) wird an unserer Schule benannt: I confirm that I have read and fully support the application of my student and agree to his / her visit to Canada, if he / she is successful in this application. I agree that our school will host a Canadian student on a reciprocal visit, and fully support them during their visit. The mentor teacher at our school for this exchange will be: Unterschrift Schulleitung