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NORTHSHORE RECOVERY HIGH SCHOOL
502 Cabot Street, Beverly, MA 01915
~ a program of the Northshore
Education Consortium
Application
for Admission
Student Information:
Student’s Name: ___________________________________________
Address: _________________________________________________
Phone:
_____________________________
Email: ______________
DOB: ________________ Gender: ___________________________
School district of residence: __________________________________
High School last enrolled in: __________________________________
Last grade completed: _______________________________________
Current/past school activities:_________________________________
Parent/Guardian
Information:
Mother’s Name/Guardian: ___________________________________
Address: _________________________________________________
Phone: (home)__________(work)___________(cell) ______________
Email: _____________________Occupation: ___________________
Father’s Name: ____________________________________________
Address: _________________________________________________
Phone: (home)
___________ (work) __________
(cell) __________
Email: ____________________Occupation: _____________________
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