Applicant Information
| Student Name: | Teshome Amenrn | Date | December 31, 2018 |
|---|---|---|---|
| Sex | Female | Place of Birth | Washington,DC, United States |
| Email Address: | gelilayeshanew@yahoo.com | Home Address | 6600 Luzon AVE NW 500 Washington, DC 20012 |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Christian | Baptized: | YES |
| Local Public School System: | Local Public School Child Would Attend: | ||
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Gelila Kelkle | Teshome Haile |
| Maiden Name | Y | F |
| Country of Birth | Ethiopia | Ethiopia |
| Home Address | 6600 Luzon AVE NW Apt 500 | 6600 Luzon AVE NW Apt 500 |
| Home Phone | (202) 352 8491 | (202) 352 7087 |
| Mother Cell Phone | (202) 352 8491 | (202) 352 7087 |
| Preferred Email | gelilayeshanew@yahoo.com | teshe2919@yahoo.com |
| Mother Occupation | Medical Assistant | Customer Service |
| Employer | Medstar Washington Hospital Center | American Air lines |
| Mother Work Phone | ||
| Religion | Christian | Christian |
| Parish/Church | The Debre Selam Kidist Mariam Church | The Debre Selam Kidist Mariam Church |
| Parents’ Marital Status: | Married | Student lives with: | |
|---|---|---|---|
| Full Name | Country of Birth | ||
| Home Address | Preferred Email | ||
| Home Phone | Cell Phone | ||
| Occupation | Employer | ||
| Work Phone | Religion | ||
| Parish/Church | Person responsible for Tuition/Fee Payments: |
||
| Address, City, State, ZIP: | Phone & Email: |
Emergency Contact Information
| Contact #1: | Kelkle Gelila | Relation to Student: | Mother |
|---|---|---|---|
| Email Address: | gelilayeshanew@yahoo.com | Home Address: | 6600 Luzon Ave NW 500 Washington, DC 20012 United States |
| Home Phone | (202) 352 8491 | Other Phone | |
| Contact #2 | Haile Teshome | Relation to Student: | Father |
| Email Address | teshe2919@yahoo.com | Home Address: | 6600 Luzon Ave NW 500 Washington, DC 20012 United States |
| Other Phone | Home Phone | (202) 352 7087 |
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? | YES |
| Does the student spend significant time with a non-English speaking caregiver? | YES |
Transferring Students
| Is the student transferring from another school(s)? | NO |
|---|
| Dates Attended | School Name | City | Phone Number | Grade Avg |
|---|---|---|---|---|
For Catholic Applicants Only
| Current Parish: | The Debre Selam Kidist Mariam Church | Pastor: |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | March 25, 2019 | The Debre Selam Kidist Mariam Church | Washington | DC |
| 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 | Gelila Kelkle |
| Father Names of Parents/Guardians | Teshome Haile |
| Mother Signatures | Gelila Kelkle |
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: |