HAILEYBURY

G E N E R A L E X C E L L E N C E S C H O L A R S H I P A P P L I C AT I O N

DETAILS OF APPLICANT
Applicants name: Date of birth: / /

Year level applying for: Gender: M F

Current school: Current year level:

Are you in receipt of any scholarship or other fee concession at your current school? Yes No

If yes, how much?

For which campus would you prefer to be considered? City Berwick Brighton Keysborough

DETAILS OF PARENT OR GUARDIAN 1

Title: Surname: Given Name:

CONTACT ADDRESS

Street/Unit number: Street name: Suburb:

State: Postcode: Country:

Phone:
( ) Mobile:

Email:

Are you an Old Haileyburian? Yes No

DETAILS OF PARENT OR GUARDIAN 2

Title: Surname: Given Name:

CONTACT ADDRESS

Street/Unit number: Street name: Suburb:

State: Postcode: Country:

Phone:
( ) Mobile:

Email:

Are you an Old Haileyburian? Yes No

SIGNATURES
A copy of your child’s two previous School Reports, NAPLAN results and any other educational, medical or psychological testing results must accompany
this application form. By signing this form, you agree to Haileybury contacting the student’s current school for further details if necessary.

Signature (Parent or Guardian 1) Signature (Parent or Guardian 2)

Name: Name:

Date: / / /
Date: /

Haileybury | 855 Springvale Road Keysborough VIC 3173 | T: +61 3 9904 6110 | E: karen.whitten@haileybury.vic.edu.au
www.haileybury.vic.edu.au | ABN 34 004 228 906 | CRICOS Nos 00649C, 02993D
 PERSONAL PARTICULARS
This section of the Application Form is to be completed by the student, NOT by the parent.

ACADEMIC

Do you often come top in any subjects? Yes No

If yes, which subjects?

Do you have any ideas yet as to which career path you wish to follow?

LEADERSHIP

Have you held a leadership position at school? Yes No

If yes, please specify

Have you held a leadership position outside of school? Yes No

If yes, please specify

SPORT

Which sports do you play?

Have you played in any teams at school? Yes No

If yes, please specify

Have you played in any club teams? Yes No

If yes, please specify

Have you been awarded any certificates, individual trophies or awards in any sport? Yes No

If yes, please specify

Haileybury | 855 Springvale Road Keysborough VIC 3173 | T: +61 3 9904 6110 | E: karen.whitten@haileybury.vic.edu.au
www.haileybury.vic.edu.au | ABN 34 004 228 906 | CRICOS Nos 00649C, 02993D
 CULTURAL

Do you do much reading? Yes No

If yes, what type of books interest you most?

Do you learn a musical instrument, play in an orchestra or band, or sing in a choir? Yes No

If yes, please specify

Do you have any hobbies or interests that you would like to mention?

OTHER

Outline any other considerations which you feel to be of importance in supporting your application.

OFFICE USE ONLY

Campus sort: Date received: / /

Interviewed by: Offer made:

Date: / / Approved by:

Please return this form along with a reference and all relevant documentation to Haileybury’s Head of Admissions.

Haileybury | 855 Springvale Road Keysborough VIC 3173 | T: +61 3 9904 6110 | E: karen.whitten@haileybury.vic.edu.au
www.haileybury.vic.edu.au | ABN 34 004 228 906 | CRICOS Nos 00649C, 02993D
Mar18