Applicant Information
| Student Name: | Washington Sir | Date | October 7, 2017 |
|---|---|---|---|
| Sex | Male | Place of Birth | Washington,DC, United States |
| Email Address: | asia_washington0228@yahoo.com | Home Address | 1215 first street northeast 5D Washington, DC 20002 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Catholic | Baptized: | YES |
| Local Public School System: | Local Public School Child Would Attend: | ||
| Race of the Student: | Black | Ethnicity of Student: | Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Asia | Washington |
| Maiden Name | ||
| Country of Birth | United States | |
| Home Address | 1215 first street northeast | 5D |
| Home Phone | ||
| Mother Cell Phone | (202) 262 4727 | |
| Preferred Email | asia_washington0228@yahoo.com | |
| Mother Occupation | Federal Government | |
| Employer | United States Census Bureau | |
| Mother Work Phone | (202) 262 4727 | |
| Religion | Catholic | |
| Parish/Church | Immaculate Conception |
| Parents’ Marital Status: | Single | Student lives with: | Mother Only |
|---|---|---|---|
| Full Name | Asia washington | Country of Birth | United States |
| Home Address | Preferred Email | asia_washington0228@yahoo.com | |
| Home Phone | Cell Phone | (202) 262 4727 | |
| Occupation | Federal Government | Employer | United States Census Bureau |
| Work Phone | (202) 262 4727 | Religion | Catholic |
| Parish/Church | Immaculate Conception | Person responsible for Tuition/Fee Payments: |
Serving our children |
| Address, City, State, ZIP: | 1707 L street northwest | Phone & Email: | (188) 329 6884 |
Emergency Contact Information
| Contact #1: | Givens Joseph | Relation to Student: | Godfather |
|---|---|---|---|
| Email Address: | josephgivens2@gmail.com | Home Address: | 1215 first street northeast 5D Washington, DC 20002 United States |
| Home Phone | (202) 904 4990 | Other Phone | |
| Contact #2 | Garcia Noel | Relation to Student: | Uncle |
| Email Address | noel.a.garcia@nagtex.com | Home Address: | 437 m street southwest Washington, DC 20024 United States |
| 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: |
Before Covid in school and at home. |
| 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)? | NO |
|---|
| Dates Attended | School Name | City | Phone Number | Grade Avg |
|---|---|---|---|---|
For Catholic Applicants Only
| Current Parish: | Immaculate Conception | Pastor: | Father Mundell |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | July 7, 2022 | |||
| 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), All relevant evaluations/assessments and previous special education plans (If Applicable) |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | |
| Mother Names of Parents/Guardians | Asia washington |
| Father Names of Parents/Guardians | |
| Mother Signatures | Asia Washington |
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: |