Applicant Information
| Student Name: | Bermudez~Smith` Seth Ean | Date | June 18, 2009 |
|---|---|---|---|
| Sex | Male | Place of Birth | Jacksonville,,Florida, United States |
| Email Address: | jberm004@gmail.com | Home Address | 3556 WARDER ST NW LOWR WASHINGTON, DC 20010-1724 |
| Siblings | [] | ||
| Name | Grade | 8th | |
| Religion: | Roman Catholic – Christ the King Church Jacksonville, FL 32211 | 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 | JESSICA NATALIA BERMUDEZ-SMITH | DARYL EDWARD SMITH |
| Maiden Name | JESSICA NATALIA EMMLINE BERMUDEZ | DARYL EDWARD SMITH |
| Country of Birth | ST CROIX, USVIRGIN ISLANDS | PEABODY ST, WASHINGTON DC USA |
| Home Address | 3556 WARDER ST NW LOWR | 12882 SHIREWOOD LN |
| Home Phone | (202) 868 1000 | |
| Mother Cell Phone | (571) 363 7539 | |
| Preferred Email | jberm004@gmail.com | |
| Mother Occupation | PUBLIC HEALTH NURSE – STATE OF VA | DENTIST |
| Employer | STATE OF VA | SELF |
| Mother Work Phone | ||
| Religion | Roman CATHOLIC | BAPTIST |
| Parish/Church | CHRIST THE KING CHURCH |
| Parents’ Marital Status: | Divorced*, Mother Remarried, Father Remarried | Student lives with: | Legal Guardian |
|---|---|---|---|
| Full Name | JESSICA NATALIA BERMUDEZ | Country of Birth | United States |
| Home Address | 3556 WARDER ST NW LOWR | Preferred Email | jberm004@gmail.com |
| Home Phone | (202) 868 1000 | Cell Phone | |
| Occupation | PUBLIC HEALTH NURSE | Employer | FAIRFAX COUNTY VA |
| Work Phone | (571) 363 7539 | Religion | ROMAN CATHULIC |
| Parish/Church | CHRIST THE KING | Person responsible for Tuition/Fee Payments: |
JESSICA BERMUDEZ |
| Address, City, State, ZIP: | 3556 WARDER ST NW LOWR, WASHINGTON DC 20010-1724 | Phone & Email: | (202) 868 1000 |
Emergency Contact Information
| Contact #1: | HENDRICKS-WHITE INGRID | Relation to Student: | GRANDMOTHER |
|---|---|---|---|
| Email Address: | ingridhendricks51@icloud.com | Home Address: | 1660 CALVIN CIRCLE KISSIMMEE, FLORIDA 34746 United States |
| Home Phone | (904) 930 1462 | Other Phone | (407) 301 4056 |
| 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)? | 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, Diagnosed Condition (specify): |
| Physical Disability: | No existing physical disability, Identified Disability (specify): |
| Learning Disorder: | No known learning disorder, Identified Disorder (specify): |
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 |
|---|---|---|---|---|
| LAURAL SPRINGS COLLEGE PREP – ONLINE ACADEMY- college-prep curr | California | 866-336-9036 |
For Catholic Applicants Only
| Current Parish: | Pastor: | Fr. James Boddie |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | July 3, 2016 | CHRIST THE KING | JACKSONVILLE | FLORIDA |
| Date Reconciliation: | May 20, 2018 | CHRIST THE KING | JACKSONVILLE | FLORIDA |
| Date First Eucharist | CHRIST THE KING | JACKSONVILLE | FLORIDA | |
| 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, Copy of Baptismal Certificate (Catholics only), Copy of custody order, or other applicable court orders (If Applicable) |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | Current standardized test scores plus the two previous years’ scores |
| Mother Names of Parents/Guardians | JESSICA NATALIA E, BERMUDEZ |
| Father Names of Parents/Guardians | |
| Mother Signatures |
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: |