APPLICATION FOR ADMISSION

Year:__________ – Grade:__________

STUDENT INFORMATION

Surname:___________________________ Given Name(s):___________________________

Date of Birth:________________________ Age:__________ Sex: __________
--------------------- (yy/mm/dd)

Student's Address:____________________________________
-------------------------- City/Province/Postal Code

Last School Attended:__________________________________

FAMILY INFORMATION

Mother's Name:____________________________

Address:__________________________________

Home Phone:______________________________

Work Phone:_______________________________

E–mail Address:____________________________

Occupation:_______________________________

Employer:_________________________________

Father's Name:____________________________

Address:__________________________________

Home Phone:______________________________

Work Phone:_______________________________

E–mail Address:____________________________

Occupation:_______________________________

Employer:_________________________________

MEDICAL INFORMATION

Family Physician:_________________________________________

Telephone Number:________________________________________

Health Insurance Number:__________________________________

Any Medical Problems:_____________________________________

Medications:_____________________________________________

Emergency Contact Person:_________________________________ Relationship:_________________________________

Home Telephone:_________________________________ Work Telephone:_________________________________

RECRUITMENT SURVEY (please check all that apply)
Please indicate how you became aware of Westboro Academy:

• Capital Parent ___

• Ottawa Citizen___

• Le Droit___

• The OSCAR___

• West Quebec Weekly___

• Yellow Pages___

• Website___

• Brochure___

• Friend/Colleague___

• Magnetic Sign on Bronson___

• Other (please specify)_____________________________

RESPONSIBILITY FOR PAYMENT

To plan its operating expenditures, Westboro Academy must assure its annual income from fees for each academic year. As such, when a student is enrolled, it is to be understood that a place is reserved for the entire school year and the parents are responsible for the annual fees in full. A $100.00 non–refundable, application fee shall accompany this application. Please make your cheque payable to Westboro Academy.

We (I) have read and understand the Westboro Academy Fee Information and agree to be bound by it.

Signature of Parent(s):

1.______________________________________________________________________________

2.______________________________________________________________________________