Applicant Information
| Student Name: | Dunn Serenity | Date | July 17, 2011 |
|---|---|---|---|
| Sex | Female | Place of Birth | Stamford,CT, United States |
| Email Address: | gabrielledunn@ymail.com | Home Address | 4501 Connecticut Ave 416 Washington, DC 20008 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Chrstian | Baptized: | NO |
| Local Public School System: | DC | Local Public School Child Would Attend: | N/A |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Gabrielle | Dunn |
| Maiden Name | ||
| Country of Birth | USA | |
| Home Address | 4501 Connecticut Ave | 416 |
| Home Phone | (347) 628 4113 | |
| Mother Cell Phone | (347) 628 4113 | |
| Preferred Email | gabrielledunn@ymail.com | gabrielledunn@ymail.com |
| Mother Occupation | Senior Admin. Assistant | |
| Employer | Seyfarth Shaw, LLP | |
| Mother Work Phone | ||
| Religion | ||
| Parish/Church |
| Parents’ Marital Status: | Single | Student lives with: | Mother Only |
|---|---|---|---|
| Full Name | Gabrielle Dunn | Country of Birth | United States |
| Home Address | 4501 Connecticut Ave | Preferred Email | gabrielledunn@ymail.com |
| Home Phone | (347) 628 4113 | Cell Phone | (347) 628 4113 |
| Occupation | Employer | ||
| Work Phone | Religion | ||
| Parish/Church | Person responsible for Tuition/Fee Payments: |
||
| Address, City, State, ZIP: | Phone & Email: |
Emergency Contact Information
| Contact #1: | Green Ronald | Relation to Student: | |
|---|---|---|---|
| Email Address: | rdgreen@comcast.net | Home Address: | |
| Home Phone | Other Phone | ||
| Contact #2 | Relation to Student: | ||
| Email Address | Home Address: | ||
| Other Phone | Home Phone |
Student Background Information
| Does your child need any particular academic enrichment in order to be successful in school? | YES |
|---|---|
| If yes, please explain briefly (other forms will be required): |
Serenity has an IEP. |
| Has your child received special services from a professional (e.g. counselor, speech therapist, special education teacher)? | YES |
| Briefly describe the type of service, length of service, and if it discontinued, a reason for discontinuation: |
Serenity receives special help in school because of her IEP |
| Does your child need accommodations to be successful in school? | YES |
| 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: | Diagnosed Condition (specify): |
| 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? | |
| 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 |
|---|---|---|---|---|
| George Washington Middle School | Alexandria, VA |
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 | |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | |
| Mother Names of Parents/Guardians | Gabrielle Dunn |
| Father Names of Parents/Guardians | |
| Mother Signatures | Gabrielle Dunn |
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: |