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									                      Alberta–Germany Short-Term Teacher Exchange
                              Alberta–Hessen Lehreraustausch                                                       Photo
                                            August and October 20____


The personal information collected in this application is pursuant to the provisions of section 33(c) of the Freedom of
Information and Protection of Privacy Act, R.S.A. 2000, cF-25 and will be used for the purposes of administering Alberta’s
educator exchange programs with the view to effect an appropriate and compatible match for the applicant. This information will
be used in accordance with the Freedom of Information and Protection of Privacy Act. Should you have any questions regarding
this activity, please contact
                                                Privacy Officer and Archivist
                                                Alberta Teachers’ Association
                                                    11010 142 Street NW
                                                  Edmonton AB T5N 2R1
                                                    Phone: 780-447-9400
                                                 Toll Free: 1-800-232-7208
Alberta teacher to Hessen, Germany, in August
German teacher to Alberta, Canada, in October
Personal Details/ Persönliche Angaben
Full Name (as it appears on passport or birth certificate)

 ___________________________________________________________________________________

Address/Adresse: ____________________________________________________________________

City/Stadt: _______________________________ Province/Landkreis: ________________________

Postal Code/Postleitzahl: ___________________ Home Phone/Telefon: ______________________

Work Phone/Telefon Geschäftlich: ______________________________________________________

Cell/Mobil: _______________________________ Fax: ____________________________________

E-mail: _____________________________________________________________________________

Date of Birth (day/month/year)/ Geburtsdatum (Tag/Monat/Jahr): ______________________________

Citizenship/Nationalität: _______________________________________________________________
Emergency Contact/Notfalladresse
Contact Person (in case of emergency)/Kontaktperson (im Notfall):

1. _________________________________________________________________________________

2. _________________________________________________________________________________

Address/Adresse

1. _________________________________________________________________________________

2. _________________________________________________________________________________


Alberta–Germany Short-Term Teacher Exchange                                   Page 1 of 6                IEEP-T-11, 2012 09
Home Phone/Telefon:                                     Work Phone/Telefon geschäftlich:

1. ______________________________________ 1. _______________________________________

2. ______________________________________ 2. _______________________________________

Languages spoken/Fremdsprachenkenntnisse:
(Please mark applicable items in bold letters)
(Bitte Zutreffendes fett markieren und unterstreichen):

1. ________________         Native speaker      Fluent/fließend   Good/gut        Basic/gering

2. ________________         Native speaker      Fluent/fließend Good/gut      Basic/gering

Education/Ausbildung (place/date/degree)

 ___________________________________________________________________________________

School Information/Schule

Name: _____________________________________________________________________________

Address/Adresse: _______________________________________                   City/Stadt: _______________________________

Province/Landkr: __________________________ Postal Code/Postleitzahl: __________________________________

Phone, with extension number/Telefon:                   Fax:

 ________________________________________               _________________________________________

Website: ____________________________________________________________________________

Description of the School/Schulangaben:
(Please mark applicable items in bold letters):
(bitte Zutreffendes fett markieren und unterstreichen):

Grade Level                  Type of School              Location                     Students
Elementary school            Public/Staatlich            Urban/städtisch              Coed/gemischt
Middle school/
junior high                  Separate                    Suburban/vorstädtisch        Boys only/Jungen
High school/
secondary school             Private/charter/privat      Rural/ländlich               Girls only/Mädchen


Approximate number of students/Schülerzahl: ______________________________________________
Approximate number of staff/Lehrerzahl: __________________________________________________

Please list any other details you feel are relevant:

 ___________________________________________________________________________________

 ___________________________________________________________________________________

Alberta–Germany Short-Term Teacher Exchange                         Page 2 of 6              IEEP-T-11, 2012 09
Current teaching assignment/Berufsfeld/Unterrichteseinsatz/Fächer:
(please include the grade level and subjects that you are teaching)

 ___________________________________________________________________________________

 ___________________________________________________________________________________

Exchange Preferences
Are there any special interests you wish to explore while on your exchange?/Gibt es spezielle
Unterrichtsbereiche, die Sie gerne während Ihres Collegeaufenthaltes erkunden würden?

 ___________________________________________________________________________________

 ___________________________________________________________________________________

Hobbies
What are your hobbies and/or special interests?/Welche sind Ihre Hobbies und speziellen Interessen?

 ___________________________________________________________________________________

 ___________________________________________________________________________________

Health
Do you suffer from any physical disabilities or allergies? (please include any food sensitivities or special
dietary needs)/ Leiden Sie unter Krankheiten oder Allergien?

 ___________________________________________________________________________________

 ___________________________________________________________________________________

Accommodation/Wohnsituation
I live in an apartment/a house that is _________ m2/ft2 and has ________ rooms, including _________
bedroom(s).

The following people also reside in my household:

 ___________________________________________________________________________________

 ___________________________________________________________________________________

I have/do not have pets. If applicable, please list the number and kind of pet(s).

 ___________________________________________________________________________________

My/Our apartment/house is located ____________ km from the school where I teach and
can be reached in ___________ minutes.

To get there I use the car/bus/train/bicycle        OR           To get there I walk

Community/neighbourhood/Umfeld–Soziales/Umfeld–Nachbarschaft
Please give a brief description of your community/neighbourhood.

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

Alberta–Germany Short-Term Teacher Exchange                        Page 3 of 6            IEEP-T-11, 2012 09
Exchange partner/Austauschpartner
I would prefer an exchange partner who is … /
Ich würde einen Austauschpartner bevorzugen, der …
(Please mark applicable items in bold letters):
(bitte Zutreffendes fett markieren und unterstreichen):

Male/männlich                       Smoker/Raucher                       Has pets
Female/weiblich                     Nonsmoker/nichtracherist             No pets
No preference                       No preference                        No preference

I would like to bring my spouse with me on my exchange             Yes             No         N/A
Please note (or be aware) that your spouse is not permitted to join (or take part in) the official
exchange program.
Bitte beachten Sie, dass Ihr Ehemann/Ihre Ehefrau nicht am offiziellen Austauschprogramm
teilnehmen kann.

I would be able to accommodate the spouse of my visiting teacher                   Yes        No

Additional Information/Zusatzinformationen

Please write a paragraph introducing yourself, your work and your interest in this program:

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________




Alberta–Germany Short-Term Teacher Exchange                      Page 4 of 6             IEEP-T-11, 2012 09
                  Alberta–Germany Short-Term Teacher Exchange
                          Alberta–Hessen Lehreraustausch
                                    August and October 20____

Release

I, ________________________ , understand that there are risks of loss in travel, in staying in someone’s
home and in hosting someone in my home. I waive my right to bring legal action against the Alberta
Teachers’ Association and Alberta Education, or any of their employees, or against the government of
the State of Hessen, Germany, for any loss incurred during the short-term teacher exchange to Germany.
I also agree to adhere to the professional code of conduct to which I am bound as a member of the
Alberta Teachers’ Association.

Accommodation Details for Billeting

By signing this application, I understand that a bedroom and bathroom must be available for billeting my
exchange partner and, perhaps, his or her spouse.


________________________________________ ________________________________________
Signature                                Witness

________________________________________
Date


Please complete this form and send it to

Educator Exchange Program
Alberta Teachers’ Association
7th floor Barnett House
11010 142 Street NW
Edmonton AB T5N 2R1
Phone: 780-447-9400
Fax: 780-455-6481
E-mail: teacher.exchange@ieep.ca




Alberta–Germany Short-Term Teacher Exchange                     Page 5 of 6            IEEP-T-11, 2012 09
                                 APPROVAL OF PRINCIPAL

As principal of _________________________________________________________ School, I


                   1. endorse the application of ______________________________________
                       (teacher) to participate in the short-term teacher exchange with Germany
                       and attest to the suitability of this candidate for this study exchange;
                   2. agree to accept the return teacher or administrator from Germany in
                       October 20       to job shadow at our school; and
                   3. will advise the board, if appropriate, of this exchange.


Principal’s Signature: ____________________________________________________________

Print Name: ___________________________________________________________________

Date: _________________________________________________________________________


Please complete this form and send it to


Educator Exchange Program
Alberta Teachers’ Association
7th floor Barnett House
11010 142 Street NW
Edmonton AB T5N 2R1
Phone: 780-447-9400
Fax: 780-455-6481
E-mail: teacher.exchange@ieep.ca




Alberta–Germany Short-Term Teacher Exchange                  Page 6 of 6         IEEP-T-11, 2012 09

								
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