Sedbergh School Application Package

Sedbergh A Co-Educational Boarding School

2009 - 2010 Application Package Checklist

Thank you for applying to Sedbergh School for the 2009-2010 school year. 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

2009 - 2010

A Co-Educational Boarding School

Application form

Student’s legal name as it appears on the birth certificate: family name

first name

Male

middle name

Female

Date of birth:

preferred name

/

/

day Insert photo of applicant here

Country of birth: Status:

month

year

Citizenship:

Canadian citizen

Landed immigrant

Study permit/visa

Student’s e-mail: Student’s home address: no

street

apt.

city

province

Application for grade (please circle):

7

Length of stay at Sedbergh:

8

country

9

10

Grades 7 or 8-12

11

12

postal code

Boarding

Grades 9-12

Day

1 year

Current school:

Grade:

no

street

Public

Private

city

province

country

postal code

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

Language of instruction:

English

French

Other languages: Spoken:

Spanish

Other:

Written:

Other schools attended: Name of school:

Year(s):

City:

Grade(s):

Name of school:

Year(s):

City:

Grade(s):

Has the student had psycho-educational testing?

Yes

Date:

No

Reason for 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

2009 - 2010

A Co-Educational Boarding School

Application form

Check if appropriate:

Mother

divorced

remarried

deceased



Father

divorced

remarried

deceased

Student lives with:

Both parents

Mother

Father

Guardian

Legal custody with:

Both parents

Mother

Father

Guardian

School reports to:

Both parents

Mother

Father

Other

Bills to:

Both parents

Mother

Father

Other

General mailings to:

Both parents

Mother

Father

Other



Parents living outside of Canada Mother Dr.

Female legal guardian

Mrs.

Ms. family name

first name

Address same as student, or: no

street

apt.

city

province

Telephone (home): (

country

)

Cellular: (

Occupation:/title: Telephone (work): (

postal code

)

Company: )

Fax: (

)

E-mail: Father Dr.

Male legal guardian Mr. family name

first name

Address same as student, or: no

street

apt.

city

province

Telephone (home): (

country

)

Cellular: (

Occupation:/title: Telephone (work): (

postal code

)

Company: )

Fax: (

)

E-mail: Emergency contact (s) ( 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

2009 - 2010

A Co-Educational Boarding School

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. Student’s legal name as it appears on the birth certificate: family name

first name

middle name

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

2009 - 2010

A Co-Educational Boarding School

Student questionnaire

What rules and consequences do you have at home? 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:

Date:

Parent signature:

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

2009 - 2010

A Co-Educational Boarding School

Parent questionnaire

Student’s legal name as it appears on the birth certificate: family name

first name

middle name

Has anyone in your family attended Sedbergh in the past?

Yes

Name:

Year(s) attended:

Name:

Year(s) attended:

preferred name

No

How did you learn about Sedbergh? Newspaper



School fair

Agent



Friend

Sedbergh Parent



Other

Boarding School Review

TABS

QAIS

CAIS

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

2009 - 2010

A Co-Educational Boarding School

Parent questionnaire

Describe your child’s academic interests and abilities. 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?

Yes

No If yes, please list:

Medication:

Reason:

Date started:

Medication:

Reason:

Date started:

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:

810 Côte Azélie

Montebello

Québec

Date:

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh

2009 - 2010

A Co-Educational Boarding School Student name:

Math teacher questionnaire Current grade:

Parental signature authorising release of information: 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:

School:

Telephone (work):

E-mail:

How long have you known the applicant?

months

years

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

No If no, please explain:

To your knowledge, does the applicant follow any remedial programmes?

Yes

No

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

Yes

No

If yes, please explain: 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

2009 - 2010

A Co-Educational Boarding School

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. AREA

1

2

3

4

5

RATING

Academic potential

Exceptional

Strong

Average

Marginal

Poor

Academic achievement

Exceptional

Strong

Average

Marginal

Poor

Academic motivation

Significant

High

Average

Lacks motivation Unmotivated

Study habits Very strong Strong Average

Requires supervision

Requires assistance

Athletic participation

Exceptional participant

Strong participant

Keen participant

Minimal participation

Little or no participation

Co-curricular activities

Exceptional leader

Real contributor Fairly active

Minor participation

Few or no activities

Conduct and behaviour

Outstanding

Excellent

Acceptable

Marginal

Poor

Exceptional

Strong

Expected

Weak

Questionable

Outstanding

Excellent

Good

Lacks concern

Unconcerned

Personal integrity Concern for others

Emotional Immature Very maturity Exceptional Age balanced appropriate Immature Relationship to peers Outstanding Excellent Acceptable Marginal Poor Relationship to adults Recommendation as a student Recommendation as a person

Outstanding

Excellent

Acceptable

Marginal

Poor

Outstanding

Excellent

Good

Weak

Poor

Outstanding

Excellent

Good

Weak

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 [email protected] www.sedberghschool.ca

Canada

Sedbergh

2009 - 2010

A Co-Educational Boarding School Student name:

English teacher questionnaire Current grade:

Parental signature authorising release of information: 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:

School:

Telephone (work):

E-mail:

How long have you known the applicant?

months

years

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

No If no, please explain:

To your knowledge, does the applicant follow any remedial programmes?

Yes

No

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

Yes

No

If yes, please explain: 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

2009 - 2010

A Co-Educational Boarding School

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. AREA

1

2

3

4

5

RATING

Academic potential

Exceptional

Strong

Average

Marginal

Poor

Academic achievement

Exceptional

Strong

Average

Marginal

Poor

Academic motivation

Significant

High

Average

Lacks motivation Unmotivated

Study habits Very strong Strong Average

Requires supervision

Requires assistance

Athletic participation

Exceptional participant

Strong participant

Keen participant

Minimal participation

Little or no participation

Co-curricular activities

Exceptional leader

Real contributor Fairly active

Minor participation

Few or no activities

Conduct and behaviour

Outstanding

Excellent

Acceptable

Marginal

Poor

Exceptional

Strong

Expected

Weak

Questionable

Outstanding

Excellent

Good

Lacks concern

Unconcerned

Personal integrity Concern for others

Emotional Immature Very maturity Exceptional Age balanced appropriate Immature Relationship to peers Outstanding Excellent Acceptable Marginal Poor Relationship to adults Recommendation as a student Recommendation as a person

Outstanding

Excellent

Acceptable

Marginal

Poor

Outstanding

Excellent

Good

Weak

Poor

Outstanding

Excellent

Good

Weak

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 [email protected] www.sedberghschool.ca

Canada

Sedbergh

2009 - 2010

A Co-Educational Boarding School

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

Male

Female

middle name

Date of birth:

/

/

day

month

preferred name

Entering grade: year

RAMQ (Quebec health card) No.:

Exp.

OHIP (Ontario health card) No.:

/

Exp.

/

All health cards must be submitted to Sedbergh School Infirmary on the day you child enters the school. Home address Mother Address:

Female Guardian

no

Tel. (w): (

Emergency address (check all that apply)

street

apt.

)

Tel. (w): (

English

Male Guardian

no

)

French

English

Spanish

postal code

)

Other:

French

Cellular: ( Spanish

postal code

)

Other: Relation:

city

Tel. (h): ( English

country

)

apt.

)

province

Name:

street

Preferred language spoken:

Cellular: (

city

Tel. (h): (

Alternate emergency contact Address: Tel. (w): (

country

)

apt.

Preferred language spoken:

province

Name:

street

no

city

Tel. (h): (

Preferred language spoken: Father Address:

Name:

province

)

French

country

Cellular: ( Spanish

postal code

)

Other:

Does you child suffer from the following?: Food/medication allergies:

Yes

Food/medication sensitivities: Seasonal allergies:

Yes

No Yes

No

Detail/reactions: No

Detail reactions:

Detail/reactions:

Has your child ever had a severe respiratory allergic reaction? Cause:

No When:

Manifestation:

Does your child have asthma? Does your child carry an inhaler? 810 Côte Azélie

Yes

Montebello

Québec

Yes Yes J0V 1L0

No

Inducing factor(s): No

Canada

Brand: Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh

2009 - 2010

A Co-Educational Boarding School

Medical information to be filled by parent/guardian

Does your child follow a restricted diet, please indicate: Vegetarian (lacto-ovo)

Vegetarian (pesce)

Vegan

Other:

Sedbergh is able to accommodate most vegetarian diets and those with mild food sensitivities. Does your child take any of the following medication? Ritalin Reason:



Dosage:

Frequency:

Concerta Reason:



Dosage:

Frequency:

Adderal Reason:



Dosage:

Frequency:

Seasonal allergy:



Dosage:

Frequency:

Supplements:



Dosage:

Frequency:

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

No

Medication:

Reason:

Dosage:

Frequency:

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?

Yes

No

When?:

Please explain: Does your child wear:

glasses

contact lenses

Is your child currently undergoing orthodontic treatment?

both Yes

No

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?

Yes Yes

No No

If yes, please explain: Will your child be able to participate fully in school sports and outdoor activities?

Yes

No

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

810 Côte Azélie

Guardian Signature:

Montebello

Québec

Date:

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh

2009 - 2010

A Co-Educational Boarding School

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

Male

first name

Female

middle name

Date of birth:

/ day

/ month

preferred name

Entering grade: year

Health history and physical examination Does the student suffer from any chronic illness?  Yes  If yes, please detail: 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

No

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

Tel:(

street

apt.

)

Montebello

province

country

postal code

E-mail:

Physician’s signature:

810 Côte Azélie

city

Date:

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca

Sedbergh

2009 - 2010

A Co-Educational Boarding School

Parents Information

Parents / Guardians Financially Responsible for: Student

Mother

Father

Other Guardian

Name:

Name:

Name:

Address:

Address:

Address:

Contact information:

Contact information:

Contact information:

Home

Home

Home

Cell

Cell

Cell

Work

Work

Work

Fax

Fax

Fax

Email

Email

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

Father

Guardian

Credit Card Authorization 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:

Visa

MasterCard

Card Number

Expiry date:

Exact name as it appears on card

Authorized Signature







Authorization valid until:

810 Côte Azélie

Montebello

Québec

J0V 1L0

Canada

Tel: 819 423 5523

Fax: 819 423 5769

www.sedberghschool.ca