Applicant Information
| Student Name: | Harris Patrick | Date | January 31, 2010 |
|---|---|---|---|
| Sex | Male | Place of Birth | ,, United States |
| Email Address: | cyndfolks@gmail.com | Home Address | 3539 A at SE 302 Washington, DC 20019 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Baptized: | NO | |
| Local Public School System: | Local Public School Child Would Attend: | Kimbell | |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Cynthia Folks | |
| Maiden Name | ||
| Country of Birth | Washington | DC |
| Home Address | 3539 A ST SE #302 | Washington DC |
| Home Phone | (202) 704 3339 | |
| Mother Cell Phone | ||
| Preferred Email | cyndfolks@gmail.com | |
| Mother Occupation | Hair stylist | |
| Employer | Gifted Hands Hair Salon | Suitland MD |
| Mother Work Phone | (202) 701 5171 | |
| Religion | ||
| Parish/Church | Holy Mountain of God |
| Parents’ Marital Status: | Single | Student lives with: | Mother Only |
|---|---|---|---|
| Full Name | Cynthia Folks | Country of Birth | United States |
| Home Address | 3539 A ST SE | Preferred Email | cyndfolks@gmail.com |
| Home Phone | Cell Phone | (202) 704 3339 | |
| Occupation | Hairstylist | Employer | Gifted Hands Hair Salon |
| Work Phone | (202) 701 5171 | Religion | Baptist |
| Parish/Church | HHMOG | Person responsible for Tuition/Fee Payments: |
Cynthia Folks |
| Address, City, State, ZIP: | 3539 A ST SE WASH.DC 20019 | Phone & Email: | (202) 704 3339 |
Emergency Contact Information
| Contact #1: | Green Anthony | Relation to Student: | Brother |
|---|---|---|---|
| Email Address: | Apgreenjr25@gmail.com | Home Address: | 4343 MLK JR AVE SW 120 Wash, DC 20032 United States |
| Home Phone | (240) 467 8925 | 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? | 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)? | YES |
| Briefly describe the type of service, length of service, and if it discontinued, a reason for discontinuation: |
He had been bullied for 5 and 6 grade |
| 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): |
Cats pollen |
| 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 |
|---|---|---|---|---|
| August 27, 2022 | National Christian Academy | Fort Washington | 3015679507 | B |
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), Copy of Baptismal Certificate (Catholics only), Allergy Action Plan (If Applicable), Copy of custody order, or other applicable court orders (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 | Cynthia Folks |
| Father Names of Parents/Guardians | |
| Mother Signatures | Cynthia Folks |
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: |