Don Valley Academy Private School Toronto, North York, Ontario, Canada

Don Valley Academy

Student Information

*Last Name:	Common Name:
*Legal 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

*Name of Course:	*Course Code

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:

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 is committed to keeping parents informed so that any critical issues, that may affect the student’s final grade, may be addressed as soon as possible. We will normally contact a parent when a student fails to achieve a mark of 70% or greater on any test or assignment. If you have other expectations, below what percentage level you would like to be contacted?

% i.e. 50, 60,.....etc

Email:

I would rather not be contacted regarding my child’s achievement throughout the course

Don Valley Academy