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Student Information
*Last Name: Middle Name:
*First Name: *Gender: M  F
*Home Phone: *Date of Birth: dd/mm/yyyy
*Street:
*City: *Postal Code:
Mobile Phone: Email:
*Country Of Birth: *Citizenship:
*OHIP Number: *Current Grade:
*Current/Previous School: *Desired Date Of Entry: dd/mm/yyyy

Parent/Guardian Information
Mother/Female Guardian
*Last Name: *First Name
Full Address (if different from student)
*Home Phone:
Mobile Phone:
Work Number:
Email Address:
Father/Male Guardian
*Last Name: *First Name:
Full Address (if different from student)
*Home Phone:
Mobile Phone:
Work Phone:
Email Address:
If parents are divorced, please state who has custody:

Student Questionnaire
Please describe your future academic plans:

What are some of your career interests?:

Which subjects do you enjoy most?:

Which subjects do you least enjoy?:

Which subjects do you hope to take this year?:

Why are you attending Don Valley Academy?:

 Please describe your current/previous community involvement:

What are some over hobbies and interests?:

Parent Questionnaire
*Has your child been diagnosed as having a learning disability?
  If yes, explain:		 YesNo

*Has your child been diagnosed as having an emotional or behavioral disorder? YesNo
*Is your child currently taking any medication?
  If yes what type(s)?		 YesNo

*Is your child currently receiving counseling?
  If yes explain:		 YesNo

*Has your child ever been suspended or expelled from school?
  If yes explain:		 YesNo

*Does your child have a criminal record? YesNo
*Does your child have any health concerns?
  If yes, explain:		 YesNo

Don Valley Academy

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