DIOCESE OF JAMAICA & THE CAYMAN ISLANDS

THE QUEEN’S SCHOOL

UPPERSIXTH FORM APPLICATION 2017/2018

INSTRUCTIONS: Complete this form in BLOCK CAPITALS. This form is

to be submitted along with two (2) passport-sized

photographs, a copy of your CAPE results.

PERSONAL INFORMATION:

Last Name / First Name / Middle Name(s)

Date of Birth: _____ / _____ / ______Gender: [ ] Male[ ] Female

DD MM YYYY

Place of Birth: ______Nationality: ______

Home Address: ______

______

Mailing Address (if different from above): ______

______

Telephone numbers: (Home) ______(Mobile) ______

E-mail Address: ______

CONTACT OF PARENT/GUARDIAN#1: (A parent or guardian with whom the student resides)

Name: ______Relationship: ______

Occupation: ______Email address: ______

Tel.: (Home) ______(Work) ______(Mobile) ______

CONTACT OF PARENT/GUARDIAN #2:

Name: ______Relationship: ______

Address: ______

Occupation: ______Email address: ______

Tel.: (Home) ______(Work) ______(Mobile) ______

RELIGIOUS AFFILIATION:

What is your religion/denomination/church? ______

Does your religion/denomination/church prevent participation in any activities? Yes ( )No ( )

If you have answered YES, explain:______

PREVIOUS SCHOOLS ATTENDED (List the most recent school attended first):

Name of Schools / Period Attended / Reason for Leaving
From / To
1.
2.
3.

CAPE Reg. No. ______Year of Entry: ______

Positions of responsibility held at most recent school: ______

______

List your involvement in Clubs & Societies: ______

______

Involvement in sporting activities: ______

REFERENCES

a)Name of Referee: ______Organization: ______

Position: ______

Address:______

______

______

Tel.: ______

b)Name of Referee: ______Organization: ______

Position: ______

Address:______

______

______

Tel.: ______

PERSONAL STATEMENT

What has been your contribution to The Queen’s School during your time as a student?(To be completed by applicants who have previously attended the school)

______

How do you intend to contribute positively to the school community as a Sixth Form student? ______

SUBJECT SELECTION

List your CSEC results in the table below:

SUBJECT / GRADE / YEAR
English A
Mathematics

List your CAPE results in the table below:

SUBJECT / GRADE / YEAR

Using the qualification information given in the table below, applicants are required to select Communication Studies and three (3) other subjects in the pools given below the qualifications table. ONE SUBJECT MUST BE SELECTED IN EACH POOL.

6A POOLS
FORM ROOMS 6AQ – RM4 6AH – RM5 6AS – RM6
POOL 1
5 sessions / Biology Sociology MOB Accounts Literature Carib. Studies
POOL 2
5 sessions / Chemistry Accounts IT Econ Carib. Studies
POOL 3
5 sessions / Mathematics Sociology Food and Nutrition MOB Geography Carib Studies
POOL 4
5 sessions / History Physics Law Literature Tourism Management Carib Studies
CARIBBEAN STUDIES (5 sessions)
NB LAW WILL BE TAUGHT 8-10 on a Thursdays and Saturdays
TOTAL SESSIONS – 25

First Career Choice:______

Second Career Choice:______

DECLARATION:

(a) I declare that the information given on this Admission Form is accurate and true. I commit to ensuring that my child/ward complies with the rules and regulations which govern students of The Queen’s School.

(b)I pledgeto provide the necessary financial and otherforms of support necessary to assist my child/ward as a student of The Queen’s School.

Name of Parent/Guardian: ______

Signature of Parent/Guardian: ______Date: _____ / _____ / ______DD MM YYYY

Signature of Applicant: ______Date: _____ / _____ / ______DD MM YYYY

FOR OFFICE USE ONLY

Interviewed by: ______Date: _____ / _____ / ______

DD MM YYYY

Year Group Coordinator’s Recommendation:______

______

APPROVED / NOT APPROVED / PENDING

Year Group Coordinator’s Signature: ______Date:_____ / _____ / ______

DD MM YYYY

Principal’s Comments:______

______

Approved by Principal: ______Date: ______

Identification #:______

Form assigned: ______

House assigned:______