Details – Catholic Schools

Applicant Information

Student Name:	Jules Matthews-Hart	Date	May 21, 2014
Sex	Male	Place of Birth	Washington,District of Columbia, United States
Email Address:	jasminhart8@gmail.com	Home Address	1628 Fort Davis Street SE ,
Siblings			[]
Name		Grade
Religion:	Baptist	Baptized:	YES
Local Public School System:	DCPS	Local Public School Child Would Attend:	Capitol Hill Montessori
Race of the Student:	Two or more races	Ethnicity of Student:	Non-Hispanic

Family Information

	Mother	Father
Full Name	Jasmin Hart
Maiden Name
Country of Birth	United States
Home Address	1628 Fort Davis Street SE
Home Phone
Mother Cell Phone	(202) 802 4389
Preferred Email	jasminhart8@gmail.com
Mother Occupation
Employer	National Education Association
Mother Work Phone
Religion	Baptist
Parish/Church	Zion Baptist Church (MD)

Parents’ Marital Status:	Single	Student lives with:	Mother Only
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:	Hart Khalia	Relation to Student:	Aunt
Email Address:	khaliahart@gmail.com	Home Address:	6003 Seat Pleasant Drive Capitol Heights, MD 20743
Home Phone	(202) 549 5282	Other Phone
Contact #2	Hart Shawn	Relation to Student:	Grandmom
Email Address	shart479@gmail.com	Home Address:	1628 Fort Davis Street SE Washington, District of Columbia 20020 United States
Other Phone	(202) 549 5282	Home Phone

Student Background Information

Does your child need any particular academic enrichment in order to be successful in school?
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:
Physical Disability:
Learning Disorder:

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
September 1, 2020	Capitol Hill Montessori	Washington, DC	202-698-4467

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	Jasmin Hart
Father Names of Parents/Guardians
Mother Signatures	Jasmin Hart

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: , :

PERSON RESPONSIBLE FOR TUITION/FEES PAYMENT

Name:		Address:
Phone Number:		NOTES: