Applicant Information
| Student Name: | Byrd DaVion | Date | April 27, 2015 |
|---|---|---|---|
| Sex | Male | Place of Birth | Washington,DC, United States |
| Email Address: | Preciousbyrd49@gmail.com | Home Address | 1128 Morse St NE Washington, DC 20002 United States |
| Siblings | Jordyn Byrd | [] | |
| Name | Jordyn Byrd | Grade | 6 |
| Religion: | Baptized: | ||
| Local Public School System: | Local Public School Child Would Attend: | Kipp North East Academy | |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Precious Byrd | Davante Dillingham |
| Maiden Name | ||
| Country of Birth | United States | United States |
| Home Address | 1128 Morse St NE | 7911 Derby Drive |
| Home Phone | (202) 655 9959 | (202) 817 9338 |
| Mother Cell Phone | (202) 446 5874 | |
| Preferred Email | Preciousbyrd49@gmail.com | Preciousx22021@gmail.com |
| Mother Occupation | Administrative Assistant | |
| Employer | Quantum Real Estate | |
| Mother Work Phone | (703) 538 6000 | |
| Religion | ||
| Parish/Church |
| Parents’ Marital Status: | Single | Student lives with: | Mother Only |
|---|---|---|---|
| Full Name | DaVion Byrd | Country of Birth | United States |
| Home Address | 1128 Morse St NE | Preferred Email | Preciousbyrd49@gmail.com |
| Home Phone | Cell Phone | (202) 446 5874 | |
| Occupation | Administrative Assistant | Employer | Quantum Real Estate |
| Work Phone | Religion | ||
| Parish/Church | Person responsible for Tuition/Fee Payments: |
Both Parents | |
| Address, City, State, ZIP: | 1128 Morse St NE | Phone & Email: | (202) 655 9959 |
Emergency Contact Information
| Contact #1: | Branch Stacey | Relation to Student: | Aunt |
|---|---|---|---|
| Email Address: | staceybranch72@gmail.com | Home Address: | 7911 Derby Drive Clinton, MD 20735 United States |
| Home Phone | (301) 792 0600 | Other Phone | (240) 476 5865 |
| Contact #2 | Byrd JoVette | Relation to Student: | Grandmother |
| Email Address | Jovette.bryant@gmail.com | Home Address: | 4938 Macdonough St Frederick, MD 21703 United States |
| Other Phone | (240) 354 3924 | Home Phone |
Student Background Information
| Does your child need any particular academic enrichment in order to be successful in school? | NO |
|---|---|
| If yes, please explain briefly (other forms will be required): | |
| Has your child received special services from a professional (e.g. counselor, speech therapist, special education teacher)? | NO |
| Briefly describe the type of service, length of service, and if it discontinued, a reason for discontinuation: | |
| Does your child need accommodations to be successful in school? | NO |
| Please list: | |
| Does your child have any diagnosed allergies? | NO |
| If yes, please list (other forms will be required): | |
| Will your child require medication to be administered during the school day? | NO |
| If yes, please explain briefly (other forms will be required): | |
| Medical Diagnosis: Please check ✓ all that apply: | No known medical conditions |
| Physical Disability: | No existing physical disability |
| Learning Disorder: | No known learning disorder |
Home Language Survey
| Primary language(s) spoken in students household: | English |
|---|---|
| Does primary guardian speak English? | YES |
| Is the Student Bi-Lingual? | NO |
| Does the student spend significant time with a non-English speaking caregiver? | NO |
Transferring Students
| Is the student transferring from another school(s)? | YES |
|---|
| Dates Attended | School Name | City | Phone Number | Grade Avg |
|---|---|---|---|---|
| Kipp Spring Academy | Washington | A |
For Catholic Applicants Only
| Current Parish: | Pastor: |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | ||||
| Date Reconciliation: | ||||
| Date First Eucharist | ||||
| Date Confirmation | ||||
| Date Other | Date Other |
Parent/Guardian Acknowledgment
| ALL STUDENT APPLICANTS | Non-Refundable Application Fee of $375.00, Copy of Valid Age Birth Certificate, Archdiocese of Washington Immunization Policy, Acknowledgment and All Attachments(Required for Admission) |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | |
| Mother Names of Parents/Guardians | Precious Byrd |
| Father Names of Parents/Guardians | Davante Dillingham |
| Mother Signatures | Precious Byrd |
For Office Use Only
| Check ✓and Date when each item is received and verified |
|---|
| Applicant Name: |
| Application Received: |
| Application Fee Paid: |
| Baptismal Certificate: |
| Immunization Documents: |
| Birth Certificate: |
| If Applicable |
| Allergy Agreement :, |
| Custody Decree: , |
| Transfer Students ONLY: |
| Report Cards: , |
| Test Scores: , |
| Admissions Interview Completed: , |
| RELIGION: , |
| Catholic |
| Non-Catholic: |
| Parish Registration Form: , |
| STATUS: |
| Accepted: , |
| Denied: , |
| Grade:, |
| Homeroom Teacher: , : |
| Name: | Address: | ||
|---|---|---|---|
| Phone Number: | NOTES: |