Sedbergh

A Co-educational boarding School
Thank you for applying to Sedbergh School for the 2009-2010 school year.

2009 - 2010
Application Package Checklist

In order to ensure you have included all required documents, please use the checklist below. Application form Student questionnaire Parent questionnaire Teacher questionnaire – Math* Teacher questionnaire – English* Medical history by physician* Medical information by parent/guardian Current year school report Final school reports – preceding two years Birth certificate – long format Passport size photos – two (If applicable) Psyche-Ed. testing results – less than 6 months old Credit Card authorization form
Application fee - $50.00** * These forms can be forwarded directly to the Admissions Office by the teacher/physician if desired. ** There is a $200.00 acceptance fee that will be invoiced upon acceptance to Sedbergh School

Once complete, please forward the complete application to: Admissions Office Sedbergh School 810 Côte Azélie Montebello Québec J0V 1L0 Canada 819-423-5523 x224

Sedbergh
A Co-educational boarding School
Student’s legal name as it appears on the birth certificate:
family name first name middle name

2009 - 2010
Application form

preferred name

Male
Insert photo of applicant here

Female

Date of birth:
day

/
month

/
year

Country of birth: Status: Canadian citizen

Citizenship: Landed immigrant Study permit/visa

Student’s e-mail: Student’s home address:
no street apt.

city

province

country

postal code

Application for grade (please circle): Length of stay at Sedbergh: Current school:
no street

7

8

9

10

11

12

Boarding 1 year

Day

Grades 7 or 8-12

Grades 9-12

Grade:
city province country postal code

Public

Private

Student’s Quebec Permanent Code:
(if applicable, on all Quebec school report cards)

Language of instruction: Other languages: Spoken: Other schools attended: Name of school: Name of school: Reason for testing:

English

French

Spanish Written:

Other:

Year(s): Year(s): Yes

City: City: Date:

Grade(s): Grade(s): No

Has the student had psycho-educational testing?

Please include copies of test reports with application

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
Check if appropriate: Student lives with: Legal custody with: School reports to: Bills to: General mailings to: Mother Father Both parents Both parents Both parents Both parents Both parents divorced divorced Mother Mother Mother Mother Mother remarried remarried Father Father Father Father Father

2009 - 2010
Application form
deceased deceased Guardian Guardian Other Other Other

Parents living outside of Canada Mother Dr. Mrs. Female legal guardian Ms.
family name first name

Address same as student, or:
no city street province country apt. postal code

Telephone (home): ( Occupation:/title: Telephone (work): ( E-mail: Father Dr. Mr.

) )

Cellular: ( Company: Fax: ( )

)

Male legal guardian
family name first name

Address same as student, or:
no city street province country apt. postal code

Telephone (home): ( Occupation:/title: Telephone (work): ( E-mail: Emergency contact (s)

) )

Cellular: ( Company: Fax: ( )

)

(
family name first name relationship telephone

)

Siblings
family name first name age school

family name

first name

age

school

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
Student’s legal name as it appears on the birth certificate:
family name first name middle name

2009 - 2010
Student questionnaire

We’re glad that you are considering Sedbergh School. This questionnaire has been designed to let us get to know you better. Please complete both sides in your own handwriting do not use a computer.

preferred name

Why do you want to attend Sedbergh School?

How do you think you will benefit from attending Sedbergh School?

What do you like about your current school?

What are your favourite subjects and why?

What don’t you like about your current school?

What sports and other activities do you enjoy?

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
What rules and consequences do you have at home?

2009 - 2010
Student questionnaire

Describe a person whom you admire or someone who has influenced you.

What do you like best about yourself?

What would you like to improve about yourself?

What do you think you will enjoy most about being at Sedbergh School?

What do you think you will dislike about being at Sedbergh School?

As a student, how will you contribute to the Sedbergh School community?

Student signature: Parent signature:

Date: Date:

Thank you for taking the time to complete this form. We look forward to meeting you
810 Côte Azélie Montebello Québec J0V 1L0 Canada Tel: 819 423 5523 Fax: 819 423 5769 www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
Student’s legal name as it appears on the birth certificate:
family name first name middle name

2009 - 2010
Parent questionnaire

preferred name

Has anyone in your family attended Sedbergh in the past? Name: Name: How did you learn about Sedbergh? Newspaper Agent Sedbergh Parent Boarding School Review TABS QAIS CAIS

Yes

No

Year(s) attended: Year(s) attended: School fair Friend Other CEC

All information provided herewith is kept in confidence and used solely for selection purposes. What are your goals and general expectations for your child?

What role do you feel Sedbergh will play to enable you to realise these goals and expectations?

What is your opinion about the general characteristics of your child? Please circle the most fitting response where: E – excellent VG - very good G – good F – fair P - poor Academic motivation Meeting academic ability Potential for academic growth Academic self-discipline Study habits Personal initiative Integrity Emotional maturity Social maturity Behaviour and conduct Personal health Co-curricular participation E E E E E E E E E E E E VG VG VG VG VG VG VG VG VG VG VG VG G G G G G G G G G G G G F F F F F F F F F F F F P P P P P P P P P P P P

What are your child’s general academic and/or social weakness and challenges?

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
Describe your child’s academic interests and abilities.

2009 - 2010
Parent questionnaire

Please summarize your child’s accomplishments and/or strengths.

What are your child’s co-curricular interests and hobbies?

What types of rules and expectations does your child have at home?

What consequences does your child have if they do not meet your expectations?

Is your child currently taking any medication? Medication: Medication:

Yes

No If yes, please list: Date started: Date started:

Reason: Reason:

How has your child adapted to taking theses medications?

It is understandable that parents apply to a variety of schools. Which ones are you considering? What types of rules and expectations does your child have at home?

I confirm that I have disclosed all particulars that will affect my child’s academic or social experience at Sedbergh School. I understand that if critical information has been withheld, Sedbergh School reserves the right to either withdraw an offer of acceptance or terminate my child’s placement at the school.

Signature of parent or guardian:

Date:

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
Student name: Parental signature authorising release of information: Current grade:

2009 - 2010
Math teacher questionnaire

The aforementioned student is applying to attend Sedbergh School. Sedbergh is a co-educational university preparatory boarding school with 90 students from grades 7 to 12. We have small class sizes and offer an integrated, outdoor experiential approach to education. Our school’s structured environment has challenging academics, sports daily, a compulsory adventure tripping programs, student government and supervised evening study. To determine every candidate’s suitability to Sedbergh, their academic potential, achievement, character and social adjustment is reviewed.

Teacher name: Telephone (work): How long have you known the applicant? Yes No If no, please explain:

School: E-mail: months years

Do you consider this applicant’s performance in your class indicative of their overall performance at school?

To your knowledge, does the applicant follow any remedial programmes? If yes, please explain:

Yes

No

Does the applicant have difficulty following school and community rules? If yes, please explain:

Yes

No

How would you describe the applicant’s interpersonal skills with his or her peers and teachers and staff?

How do you think the applicant will adjust to a structured boarding school environment?

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
AREA Academic potential Academic achievement Academic motivation Study habits Athletic participation Co-curricular activities Conduct and behaviour Personal integrity Concern for others Emotional maturity Relationship to peers Relationship to adults Recommendation as a student Recommendation as a person 1 Exceptional Exceptional Significant Very strong Exceptional participant Exceptional leader Outstanding Exceptional Outstanding Exceptional Outstanding Outstanding Outstanding Outstanding 2 Strong Strong High Strong Strong participant Real contributor Excellent Strong Excellent Age Excellent Excellent Excellent Excellent 3 Average Average Average Average Keen participant Fairly active Acceptable Expected Good Immature balanced Acceptable Acceptable Good Good 4 Marginal Marginal Lacks motivation Requires supervision Minimal participation Minor participation Marginal Weak Lacks concern Very appropriate Marginal Marginal Weak Weak 5 Poor Poor

2009 - 2010
Math teacher questionnaire

We would appreciate your observations about the areas identified below. Please mark your rating in the column on the right, where 1 is outstanding and 5 is poor. RATING

Unmotivated Requires assistance Little or no participation Few or no activities Poor Questionable Unconcerned Immature Poor Poor Poor Poor

Thank you in advance for taking the time to facilitate this student’s entry to Sedbergh Please forward this form to: Admissions Office Sedbergh School 810 Côte Azélie Montebello Québec J0V 1L0 Fax : (819) 423-5769 admissions@sedbergh.com www.sedberghschool.ca Canada

Sedbergh
A Co-educational boarding School
Student name: Parental signature authorising release of information: Current grade:

2009 - 2010
english teacher questionnaire

The aforementioned student is applying to attend Sedbergh School. Sedbergh is a co-educational university preparatory boarding school with 90 students from grades 7 to 12. We have small class sizes and offer an integrated, outdoor experiential approach to education. Our school’s structured environment has challenging academics, sports daily, a compulsory adventure tripping programs, student government and supervised evening study. To determine every candidate’s suitability to Sedbergh, their academic potential, achievement, character and social adjustment is reviewed.

Teacher name: Telephone (work): How long have you known the applicant? Yes No If no, please explain:

School: E-mail: months years

Do you consider this applicant’s performance in your class indicative of their overall performance at school?

To your knowledge, does the applicant follow any remedial programmes? If yes, please explain:

Yes

No

Does the applicant have difficulty following school and community rules? If yes, please explain:

Yes

No

How would you describe the applicant’s interpersonal skills with his or her peers and teachers and staff?

How do you think the applicant will adjust to a structured boarding school environment?

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
AREA Academic potential Academic achievement Academic motivation Study habits Athletic participation Co-curricular activities Conduct and behaviour Personal integrity Concern for others Emotional maturity Relationship to peers Relationship to adults Recommendation as a student Recommendation as a person 1 Exceptional Exceptional Significant Very strong Exceptional participant Exceptional leader Outstanding Exceptional Outstanding Exceptional Outstanding Outstanding Outstanding Outstanding 2 Strong Strong High Strong Strong participant Real contributor Excellent Strong Excellent Age Excellent Excellent Excellent Excellent 3 Average Average Average Average Keen participant Fairly active Acceptable Expected Good Immature balanced Acceptable Acceptable Good Good 4 Marginal Marginal Lacks motivation Requires supervision Minimal participation Minor participation Marginal Weak Lacks concern Very appropriate Marginal Marginal Weak Weak 5 Poor Poor

2009 - 2010
english teacher questionnaire

We would appreciate your observations about the areas identified below. Please mark your rating in the column on the right, where 1 is outstanding and 5 is poor. RATING

Unmotivated Requires assistance Little or no participation Few or no activities Poor Questionable Unconcerned Immature Poor Poor Poor Poor

Thank you in advance for taking the time to facilitate this student’s entry to Sedbergh Please forward this form to: Admissions Office Sedbergh School 810 Côte Azélie Montebello Québec J0V 1L0 Fax : (819) 423-5769 admissions@sedbergh.com www.sedberghschool.ca Canada

Sedbergh
A Co-educational boarding School

2009 - 2010
Medical information to be filled by parent/guardian

Please complete the following in full and return to Sedbergh School as soon as possible. All international students are required to have heath insurance coverage for Canada. The policy will be purchased by Sedbergh on behalf of the student. The cost of the insurance is charged on the invoice accompanying the contract. The heath insurance policy does not include dental or orthodontic care. It is recommended that your child has a full dental check-up prior to coming to Sedbergh. All costs incurred for health and dental procedures will be billed directly to the student’s account. Cost of transportation to and from appointments will also be billed to the student’s account. Student’s legal name:
family name first name middle name preferred name

Male

Female

Date of birth:
day

/
month

/
year

Entering grade: Exp. Exp. / /

RAMQ (Quebec health card) No.: OHIP (Ontario health card) No.:

All health cards must be submitted to Sedbergh School Infirmary on the day you child enters the school. Home address Mother Address:
no

Emergency address (check all that apply) Name:
apt. city province country postal code

Female Guardian
street

Tel. (w): (

)

Tel. (h): ( English Name:
apt.

) Spanish Other:

Cellular: (

)

Preferred language spoken: Father Address:
no

French

Male Guardian
street

city

province

country

postal code

Tel. (w): (

)

Tel. (h): ( English French

) Spanish Other:

Cellular: (

)

Preferred language spoken:

Alternate emergency contact Address:
no street

Name:
apt. city province

Relation:
country postal code

Tel. (w): (

)

Tel. (h): ( English French

) Spanish Other:

Cellular: (

)

Preferred language spoken:

Does you child suffer from the following?: Food/medication allergies: Food/medication sensitivities: Seasonal allergies: Cause: Does your child have asthma? Does your child carry an inhaler?
810 Côte Azélie Montebello Québec

Yes Yes No

No

Detail/reactions: No Detail reactions: Yes No When:

Yes

Detail/reactions: Manifestation:

Has your child ever had a severe respiratory allergic reaction? Yes Yes
J0V 1L0

No No

Inducing factor(s): Brand:
Tel: 819 423 5523 Fax: 819 423 5769 www.sedberghschool.ca

Canada

Sedbergh
A Co-educational boarding School
Does your child follow a restricted diet, please indicate: Vegetarian (lacto-ovo) Vegetarian (pesce) Vegan Other: Does your child take any of the following medication? Ritalin Reason: Concerta Reason: Adderal Reason: Seasonal allergy: Supplements: Yes Reason: No Medication: Dosage: Frequency: Dosage: Dosage: Dosage: Dosage: Dosage: Frequency: Frequency: Frequency: Frequency: Frequency:

2009 - 2010
Medical information to be filled by parent/guardian

Sedbergh is able to accommodate most vegetarian diets and those with mild food sensitivities.

Will your child be on this or any other medication while at Sedbergh?

All medications must be passed to the nursing staff upon arrival in September or when your child returns to school following breaks and holidays. Has your child been hospitalized or sustained serious injury? Please explain: Does your child wear: glasses contact lenses both Yes No Yes Yes Yes No No No Is your child currently undergoing orthodontic treatment? Yes No When?:

Will your child be required to undergo orthodontic treatment while at Sedbergh? Does your child have any other health issues of which the school should be aware? If yes, please explain: Will your child be able to participate fully in school sports and outdoor activities? If no, please explain: Does your child know how to swim?  Yes  NoHow far?  <25m < 50m  >100m

Do you have any other comments concerning your child’s physical, psychological and social development as it pertains to their experience at Sedbergh?Sedbergh? If you would prefer your child to take homeopathic medication please contact the school nurse directly. I, the undersigned, certify that all information disclosed herewith is complete and correct. I, the undersigned, understand that all medications prescribed to my child must be kept in the Sedbergh Infirmary and administered by the nursing staff or designated personnel. I, the undersigned, hereby give permission to Sedbergh School and its designates to initiate emergency procedures in the event of sudden accident or illness of my child. Parent Guardian Signature: Date:

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School

2009 - 2010
Medical history to be completed by physician

Sedbergh School is a co-educational boarding school located in Quebec Canada. Our rigorous outdoor sports and camping program requires students to participate in a variety of activities including cross country running, cross country skiing, hiking, lake swimming and canoeing. As a boarding facility, we require all students to have current and accurate medical information on file. The following form must be completed in full, signed by a physician and returned to Sedbergh School as soon as possible. Student’s legal name:
family name first name middle name preferred name

Male

Female

Date of birth:
day

/
month

/
year

Entering grade:

Health history and physical examination Does the student suffer from any chronic illness?  If yes, please detail: Yes  No

Please detail past or recent disorders or conditions: Chicken Pox No Yes Date: Measles No Yes Date: Malaria No Yes Date: Meningitis No Yes Date: Mumps No Yes Date: Rubella No Yes Date: Scarlet/rheumatic fever No Yes Date: Hepatitis No Yes Date: Tuberculosis No Yes Date: Urinary No Yes Date: Headache/migraine No Yes Date: Fainting spells No Yes Date: Scoliosis No Yes Date: Eyes No Yes Date: Ears No Yes Date: Nose No Yes Date: Throat No Yes Date: Heart No Yes Date: Lung No Yes Date: Abdomen No Yes Date: Genitalia No Yes Date: First period No Yes Date: Skin No Yes Date: Muscular-skeletal No Yes Date: Neurological No Yes Date: Behavioural No Yes Date: Emotional No Yes Date:
810 Côte Azélie Montebello Québec J0V 1L0 Canada

Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details: Details:
Tel: 819 423 5523 Fax: 819 423 5769 www.sedberghschool.ca

Sedbergh
A Co-educational boarding School

2009 - 2010
Medical history to be completed by physician

If a current copy of the student’s immunization record is available, please attach and sign below. Information written in bold is required by all students. Those who are returning to Sedbergh School for a consecutive year of study are not required to complete the remaining list.

VACCINATION

DATE

DATE

DATE

DATE

DATE

DPT DT Tetanus Polio Measles Mumps Rubella Hepatitis A Hepatitis B Meningitis Tuberculosis Other: Other:

Will this student be able to participate fully in our sports and outdoor activity programs? Yes No If no, please detail

Physician’s name
(please print)

Address:
no street apt. city province country postal code

Tel:(

)

E-mail:

Physician’s signature:

Date:

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh
A Co-educational boarding School
Parents / Guardians Financially Responsible for: Student

2009 - 2010
Parents Information

Mother Name: Address: Name: Address:

Father Name:

Other Guardian

Address:

Contact information:

Contact information:

Contact information:

Home Cell Work Fax Email

Home Cell Work Fax Email

Home Cell Work Fax Email

Sedbergh is hereby authorized to contact the persons above in the event of emergency and to send marks, transcripts, reports or other information or correspondence pertaining to the student to: (persons signing
contract initial all that apply)

Mother Credit Card Authorization

Father

Guardian

I hereby authorize you to charge my below listed credit card for: (please check one) All expenses, including tuition, residence fees, and monthly charges. Monthly charges only Card type: Card Number Exact name as it appears on card Visa MasterCard Expiry date: Authorized Signature

Authorization valid until:

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

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