Applicant Information
| Student Name: | Frederick Kayden | Date | January 28, 2011 |
|---|---|---|---|
| Sex | Female | Place of Birth | Midlothian,Virginia, United States |
| Email Address: | TFrederick1@hotmail.com | Home Address | 6317 Colebrook Road Henrico, Virginia 23227 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Christianity | Baptized: | YES |
| Local Public School System: | Chesterfield County Public School in Chesterfield Virginia | Local Public School Child Would Attend: | |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Treseat Frederick | Jeffrey Frederick |
| Maiden Name | Young | |
| Country of Birth | USA | USA |
| Home Address | 6317 Colebrook Road | 6317 Colebrook Road |
| Home Phone | ||
| Mother Cell Phone | (804) 245 3340 | (804) 245 2984 |
| Preferred Email | TFrederick1@hotmail.com | JFrederick@hotmail.com |
| Mother Occupation | Lead Program Coordinator | Property Manager |
| Employer | DC Government | Dreyfuss Management |
| Mother Work Phone | (202) 727 4261 | (202) 462 6004 |
| Religion | Christian | Christian |
| Parish/Church | St. Pauls Baptist Church | St. Pauls Baptist Church |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Jeffrey and Treseat Frederick | Country of Birth | United States |
| Home Address | 6317 Colebrook Road Henrico Virginia 23227 | Preferred Email | TFrederick1@hotmail.com |
| Home Phone | Cell Phone | (804) 245 3340 | |
| Occupation | Employer | ||
| Work Phone | Religion | ||
| Parish/Church | Person responsible for Tuition/Fee Payments: |
Parents | |
| Address, City, State, ZIP: | Phone & Email: |
Emergency Contact Information
| Contact #1: | Young Adora | Relation to Student: | Sister |
|---|---|---|---|
| Email Address: | adora.young@gmail.com | Home Address: | 6011 New Forest Ct. #2 Waldorf, Maryland 20603 United States |
| Home Phone | (804) 245 7912 | Other Phone | |
| Contact #2 | Irwin James | Relation to Student: | Uncle |
| Email Address | Home Address: | 3506 25th Ave Temple Hills, Maryland 20748 United States |
|
| Other Phone | Home Phone | (202) 981 9640 |
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? | YES |
| If yes, please list (other forms will be required): |
Seasonal Allergies |
| 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? | NO |
| 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 |
|---|---|---|---|---|
| June 14, 2023, June 14, 2022 | Providence Middle School, A M Davis Elementary | Chesterfield, Chesterfield Virginia | 804-674-1355, 804-674-1310 | 3.5, 3.5 |
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 |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | Current report card including comments and the two previous years’ report cards |
| Mother Names of Parents/Guardians | Treseat Frederick |
| Father Names of Parents/Guardians | Jeffrey Frederick |
| Mother Signatures | Treseat Frederick |
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: |