APPLICATION FOR ADMISSION

BEAVER VALLEYS EDUCATIONAL ADVANTAGE

APPLICANT INFORMATION
Name of Applicant _______________________________________________________________
Last

First
(Preferred)

Address_________________________________________________________________________
City _________________________________ Province _____________________
Postal Code ___________________________ Home Phone _______________________
Preferred Email Address ____________________________________________________________
Date of Birth ____________________________

Country of Birth _________________

Present School _____________________________

Present Grade __________________

Type of School: Independent

Private

Public

Separate

Other

First Language __________________________ Other Languages Spoken _______________

Does your child have any medical conditions, physical/social/emotional limitations or needs of which we
should be aware?

YesNo If yes, please explain ________________________________

_____________________________________________________________________
Has your child had a Psycho-Educational Assessment, any Educational Testing, or any
Therapeutic Support? If so, please attach details.
(e.g. Occupational or Speech Therapy)? Yes No

Send to Headwaters Academy, c/o Principal Mark Brown, 392269 Grey Road 109, Holstein, ON N0G 2A0
or scan and send to beavervalleyschool@gmail.com.

Parent / Guardian 1: Dr. Mr. Mrs. Ms _____________________________________

Address (if different from page 1) _________________________________________________
____________________________________________________________________________
Home Phone: ___________________

Work Phone: ______________________________

Cell: __________________________

Place of Employment: _______________________

Occupation: ____________________

Email address: ____________________________

Parent / Guardian 2: Dr. Mr. Mrs. Ms _____________________________________

Address (if different from page 1) _________________________________________________
____________________________________________________________________________
Home Phone: ___________________

Work Phone: ______________________________

Cell: __________________________

Place of Employment: _______________________

Occupation: ____________________

Email address: ____________________________

Applicant lives with:

Both Parents Mother

Check if applicable: Sole Custody

Father
Sole Custody

Correspondence should be sent to:

Both Parents Mother

Father

Please list the names of the Applicants brothers and sisters.

Name

School and Grade

Date of Birth

_________________________________________________________________________
____________________________________________________________________________
All information in this Application for Admission is strictly confidential. The undersigned grants Headwaters Academy permission to
request and receive confidential information regarding the applicant and to retain such material in the applicants file. If the
candidate is admitted to Headwaters Academy,we undertake jointly, and severally, to be responsible for all financial obligations
incurred by the applicant at Headwaters Academy.

I / we certify that all information provided is accurate and true.

Parent or Legal Guardian Signature: _______________________________ Date: ______________

Parent or Legal Guardian Signature: _______________________________ Date: ______________

Send to Headwaters Academy, c/o Principal Mark Brown, 392269 Grey Road 109, Holstein, ON N0G 2A0
or scan and send to beavervalleyschool@gmail.com.