Applicant Information
| Student Name: | Johnson Zuri | Date | January 16, 2020 |
|---|---|---|---|
| Sex | Female | Place of Birth | Providence,RI, United States |
| Email Address: | gmoore1204@gmail.com | Home Address | 2919 North Capitol St NE Washington, DC 20002 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Christian | Baptized: | |
| 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 | Grace Moore | Wes Johnson |
| Maiden Name | ||
| Country of Birth | Liberia | USA |
| Home Address | ||
| Home Phone | ||
| Mother Cell Phone | (401) 441 2501 | (339) 218 0770 |
| Preferred Email | gmoore1204@gmail.com | |
| Mother Occupation | LICSW | |
| Employer | Arising Behavioral Health and Services | |
| Mother Work Phone | ||
| Religion | Christian | |
| Parish/Church |
| Parents’ Marital Status: | Single | Student lives with: | Mother Only |
|---|---|---|---|
| Full Name | Grace Moore | Country of Birth | Liberia |
| Home Address | 2919 North Capitol St NE, 20002 | Preferred Email | gmoore1204@gmail.com |
| Home Phone | Cell Phone | (401) 441 2501 | |
| Occupation | LICSW | Employer | Arising Behavioral Health and Services |
| Work Phone | Religion | ||
| Parish/Church | Person responsible for Tuition/Fee Payments: |
Grace Moore | |
| Address, City, State, ZIP: | Phone & Email: |
Emergency Contact Information
| Contact #1: | Saygbay Celia | Relation to Student: | Aunty |
|---|---|---|---|
| Email Address: | ksaygbay@gmail.com | Home Address: | 2301 Hunter St Baltimore, MD 21218 United States |
| Home Phone | (443) 374 7317 | Other Phone | |
| Contact #2 | Watson Jaydee | Relation to Student: | Aunty |
| Email Address | jayashdes@gmail.com | Home Address: | 16 Armistice Blvd Pawtucket, RI 02860 United States |
| Other Phone | (508) 840 6264 | 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 |
|---|---|---|---|---|
| Way to Grow Early learning center | North Providence | 4012311171 |
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 | Grace Moore |
| Father Names of Parents/Guardians | |
| Mother Signatures | Grace Moore |
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: |