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International Summer School North Country School 4382 Cascade Road

Lake Placid, NY 12946 Telephone (518) 523-9329 Fax (518) 523-4858

iss@northcountryschool.org

International Summer School (ISS) Application Please note: If you have completed the online application, you do not need to fill out this form. Student Information Student’s full name: ___________________________________________________________ Student’s name exactly as it appears on his or her passport Student prefers to be called: ___________________________ Gender: _________________ Date of birth: _______________________ Age as of June 30, 2014: __________ _________ month / day / year years months Country of Citizenship: _________________________________________________________ Place of birth: _______________________________________ Current grade: ____________ To which summer session is your child applying? _____ Summer Session I: July 5 - July 26 (Tuition: $5,000) _____ Summer Session II: July 27 - August 17 (Tuition: $5,000) _____ Both Summer Sessions: July 5 - August 17 (Tuition: $9,000) Contact Information Primary parent name(s): ________________________________________________________ Spouse or partner’s name: ______________________________________________________ Relation to student: ____________________________________________________________ Are the student’s parents divorced? __________ With whom does the student live? _________

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Primary parent address: ____________________________________________

___________________________________________________ Street address

___________________________________________________ Postal code ___________________________________________________ Country Home phone: ______________________ Work phone: _______________________________ Email address: ________________________________________________________________ Optional Secondary Parent/Guardian Contact Information Parent/Guardian name: _________________________________________________________ Spouse or partner’s name: ______________________________________________________ Relation to student: ____________________________________________________________ Parent/Guardian address: ___________________________________________

___________________________________________________ Street address

___________________________________________________ Postal code ___________________________________________________ Country Home phone: _______________________ Work phone: _____________________________ Email address: ________________________________________________________________ Optional Referring Consultant Contact Information Consultant’s name: _____________________ Agency name: ___________________________ Email address: ____________________________ Phone: ____________________________ School Information Name of your child’s school: _________________________________________ School address: __________________________________________________ Street address

__________________________________________________ Postal code __________________________________________________ Country School phone: ____________________ School website:______________________________ Personal Information To help us know your child, please provide responses to the following questions.

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1. What are your child’s strengths? What does your child love most to do and do best? 2. What are your child's weaknesses, including areas of growth, things that this child likes least and does least well?

3. Please tell us where and for how many years your child has received English instruction. 4. Has your child traveled to or studied in an English speaking country? Please explain.

5. Has your child taken the TOEFL Junior Test? _____Yes, I will send the test scores. _____ No, my child has not taken the test. 6. Has your child attended overnight camp? ________ Yes ________ No Name and location of camp / length of camp: 7. Has your child ever had any serious physical problems, illnesses, or injuries? If so, please describe and include the age(s) when these occurred.

General Information 8. How did you hear about the International Summer School at North Country School? 9. Have any relatives or friends attended North Country School? Please list.