Applicant Information
| Student Name: | Fiala India | Date | April 6, 2011 |
|---|---|---|---|
| Sex | Female | Place of Birth | Washington,DC, United States |
| Email Address: | annetoe@gmail.com | Home Address | 643 K street NE Washington, DC 20002 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Episcopalian | Baptized: | NO |
| Local Public School System: | DCPS | Local Public School Child Would Attend: | Stuart Hobson MS |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Anne Fiala | Eric Fiala |
| Maiden Name | Toeniskoetter | |
| Country of Birth | USA | USA |
| Home Address | 643 K street NE | 643 K street NE |
| Home Phone | (651) 497 1060 | (952) 994 1641 |
| Mother Cell Phone | (651) 497 1060 | (952) 994 1641 |
| Preferred Email | annetoe@gmail.com | ericjfiala@gmail.com |
| Mother Occupation | government | finance |
| Employer | USDA | FINRA |
| Mother Work Phone | ||
| Religion | Lutheran | Catholic |
| Parish/Church | Christ Church Washington Parish | Christ Church Washington Parish |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Anne Fiala | Country of Birth | United States |
| Home Address | 643 K street NE | Preferred Email | annetoe@gmail.com |
| Home Phone | (651) 497 1060 | Cell Phone | (651) 497 1060 |
| Occupation | Government | Employer | USDA |
| Work Phone | Religion | Lutheran | |
| Parish/Church | Christ Church Washington Parish | Person responsible for Tuition/Fee Payments: |
Eric Fiala |
| Address, City, State, ZIP: | 643 K street NE, Washington, DC 20002 | Phone & Email: | (952) 994 1641 |
Emergency Contact Information
| Contact #1: | Diamond-Falk Emily | Relation to Student: | Family Friend |
|---|---|---|---|
| Email Address: | emilydf@gmail.com | Home Address: | 919 6th St NE Washington, DC 20002 United States |
| Home Phone | (202) 336 4980 | Other Phone | |
| Contact #2 | Shore Dan | Relation to Student: | Family Friend |
| Email Address | dashore@gmail.com | Home Address: | 230 11th St SE Washington, DC 20003 United States |
| Other Phone | Home Phone | (617) 548 5446 |
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: | Identified Disorder (specify): |
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 |
|---|---|---|---|---|
| January 1, 2023, September 1, 2022, September 1, 2020, September 1, 2016, September 1, 2014 | Stuart-Hobson Middle School, Two Rivers Middle School, Two Rivers Elementary, J.O. Wilson Elementary, West Education Campus | Washington, Washington, Washington, Washington, Washington | 202-671-6010, 202-388-3177, 202-546-4477, 202-698-4733 |
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), Allergy Action Plan (If Applicable), All relevant evaluations/assessments and previous special education plans (If Applicable) |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | Current standardized test scores plus the two previous years’ scores, Current report card including comments and the two previous years’ report cards |
| Mother Names of Parents/Guardians | Anne Fiala |
| Father Names of Parents/Guardians | Eric Fiala |
| Mother Signatures | Anne Fiala |
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: |