Desarrollo de programas lingüísticos en Europa
Proyecto: Erasmus+
MOBILITY VET PROJECTS – DATA COLLECTION FORM
Erasmus+ Project, title “Desarrollo de programas lingüísticos en Europa”
n. convention 2015-1 ES01-KA101-015356
Surname: ARTEAGA ARGANDOÑA
First Name: MARIA
Sex: Male Female X
Place & date of birth: ALBACETE 26/4/83
Nationality: SPANISH
Address: MARQUES DE VILLORES, 48, STREET.
E-mail: monamaria83@hotmail.com
Mobile: 651996342
ID Skype: …………………………………………………………
What is your mother tongue? SPANISH
What is your level of Italian Language? · High · Medium · Low X Nothing
What is your level of English Language? · High · Medium X Low · Nothing
Do you know another foreign language? Yes No X
If yes specify which and level …………………………………..
X Long term Employed · Temporarily Employed · Self-Employed · Redundant
· Unemployed · Recent Graduates · Student · Trainee
Yes X No
If yes specify: …A SCHOOL.................................................................................................................….........….....
Are you allergic to dust, fealthers, pollen, animal, others? Yes No X
If yes, specify: ...........................................................................................................................……...................................
Do you smoke? Yes No X
Do you drink alcohol? Never Sometimes X Frequently
Do you need medicine for any reason? Yes No X
Do you need a doctor frequently for any reason? Yes No X
Do you have psycological impairment that would limit your role/activity on the training course? Yes No X
Do you have physical impairment that would limit your role/activity on the training course? Yes No X
Have you been hospitalized within the past ten years? Yes No X
If you answered yes to any of above questions, please explain in detail. (Attach additional sheets if necessary)
...........……............................................................................................................................................................................
........................……...............................................................................................................................................................
Name and Surname: JUANA ARGANDOÑA MORENO
Relation to Yourself: MY MOTHER
Full Address: MARQUES DE VILLORES STREET, 48, 1ºC, ALBACETE, SPAIN
Telephone: 967618675
Mobile: 630730514
Email: ………………………………………….
I undersigned declare that I have completed the application form of my own free will and all the above information is true. I accept full responsability for incompleted answers or false information. I undersigned, take responsibility and knowledge about all the information above and give my permission for the use of personal data to be distributed, comunicated and transfered abroad.
Location/Date:...TOMELLOSO, 26/4/2016..... Signed: .......................................................................
8. DECLARATION OF RESPONSIBILITY
7. EMERGENCY FORM (In case of emergency)
6. MEDICAL HEALTH HISTORY
5 ACCOMMODATION INFORMATIONS
4. ARE YOU NOW ATTENDING A SCHOOL, A COURSE, A TRAINING, OR OTHER?
3. CURRENT OCCUPATION
2. LANGUAGES
1. PERSONAL DATA
MOBILITY VET PROJECTS – DATA COLLECTION FORM
Erasmus+ Project, title “Desarrollo de programas lingüísticos en Europa”
n. convention 2015-1 ES01-KA101-015356
Surname: MARTINEZ SERNA
First Name: FLOR
Sex: Male Female X
Place & date of birth: TOMELLOSO
Nationality: SPANISH
Address: AMPARO STREET N.10 HOUSE 12- 13700 Tomelloso (CR)- Spain
E-mail: flower032@hotmail.com
Mobile: 629672011
ID Skype: …………………………………………………………
What is your mother tongue? SPANISH
What is your level of Italian Language? · High · Medium · Low X Nothing
What is your level of English Language? · High X Medium · Low · Nothing
Do you know another foreign language? Yes No X
If yes specify which and level …………………………………..
X Long term Employed · Temporarily Employed · Self-Employed · Redundant
· Unemployed · Recent Graduates · Student · Trainee
Yes No X
If yes specify: ….................................................................................................................….........….....
Are you allergic to dust, fealthers, pollen, animal, others? Yes X No
If yes, specify: .................DUST AND POLLEN.....................................
Do you smoke? Yes No X
Do you drink alcohol? Never X Sometimes Frequently
Do you need medicine for any reason? Yes X No
Do you need a doctor frequently for any reason? Yes No X
Do you have psycological impairment that would limit your role/activity on the training course? Yes No X
Do you have physical impairment that would limit your role/activity on the training course? Yes No X
Have you been hospitalized within the past ten years? Yes No X
If you answered yes to any of above questions, please explain in detail. (Attach additional sheets if necessary)
...........……............................................................................................................................................................................
........................……...............................................................................................................................................................
Name and Surname: CARMEN SERNA PINO
Relation to Yourself: MOTHER
Full Address: ALCAZAR STREET N.25- Tomelloso (CR)- Spain
Telephone: 926510098
Mobile: 626595396
Email: c_armen_serna@hotmail.com
I undersigned declare that I have completed the application form of my own free will and all the above information is true. I accept full responsability for incompleted answers or false information. I undersigned, take responsibility and knowledge about all the information above and give my permission for the use of personal data to be distributed, comunicated and transfered abroad.
Location/Date: Tomelloso, 26th of April of 2016 Signed: .......................................................................
2. LANGUAGES
3. CURRENT OCCUPATION
4. ARE YOU NOW ATTENDING A SCHOOL, A COURSE, A TRAINING, OR OTHER?
5 ACCOMMODATION INFORMATIONS
6. MEDICAL HEALTH HISTORY
7. EMERGENCY FORM (In case of emergency)
8. DECLARATION OF RESPONSIBILITY
MOBILITY VET PROJECTS – DATA COLLECTION FORM
8. DECLARATION OF RESPONSIBILITY
7. EMERGENCY FORM (In case of emergency)
6. MEDICAL HEALTH HISTORY
5 ACCOMMODATION INFORMATIONS
4. ARE YOU NOW ATTENDING A SCHOOL, A COURSE, A TRAINING, OR OTHER?
3. CURRENT OCCUPATION
2. LANGUAGES
1. PERSONAL DATA
Erasmus+ Project, title “Desarrollo de programas lingüísticos en Europa”
n. convention 2015-1 ES01-KA101-015356
Surname: CARAMENA HERRERA
First Name: LAURA
Sex: Male Female X
Place & date of birth: Manzanares, 30th of October of 1979
Nationality: SPANISH
Address: CAMPO STREET N. 86 ATICO D- 13700 Tomelloso (CR)- Spain
E-mail: lauracamarenaherrera@gmail.com
Mobile: 606293964
ID Skype: …………………………………………………………
What is your mother tongue? SPANISH
What is your level of Italian Language? · High · Medium · Low X Nothing
What is your level of English Language? · High X Medium · Low · Nothing
Do you know another foreign language? Yes No X
If yes specify which and level …………………………………..
X Long term Employed · Temporarily Employed · Self-Employed · Redundant
· Unemployed · Recent Graduates · Student · Trainee
Yes X No
If yes specify: ….............ATTENDING A SCHOOL....................................................................................................….........….....
Are you allergic to dust, fealthers, pollen, animal, others? Yes X No
If yes, specify: .................POLLEN.....................................
Do you smoke? Yes No X
Do you drink alcohol? Never Sometimes X Frequently
Do you need medicine for any reason? Yes No X
Do you need a doctor frequently for any reason? Yes No X
Do you have psycological impairment that would limit your role/activity on the training course? Yes No X
Do you have physical impairment that would limit your role/activity on the training course? Yes No X
Have you been hospitalized within the past ten years? Yes No X
If you answered yes to any of above questions, please explain in detail. (Attach additional sheets if necessary)
...........……............................................................................................................................................................................
........................……...............................................................................................................................................................
Name and Surname: GERONIMA HERRERA JIMENEZ
Relation to Yourself: MOTHER
Full Address: SAN MARCOS STREET N. 45 1º F- 13200 Manzanares (CR )- Spain
Telephone: 926611882
Mobile: 620954662
Email: hjgero@hotmail.com
I undersigned declare that I have completed the application form of my own free will and all the above information is true. I accept full responsability for incompleted answers or false information. I undersigned, take responsibility and knowledge about all the information above and give my permission for the use of personal data to be distributed, comunicated and transfered abroad.
Location/Date: Tomelloso, 26th of April of 2016 Signed: .......................................................................
