Applicant Information
| Student Name: | Whitaker Terry | Date | October 24, 2013 |
|---|---|---|---|
| Sex | Male | Place of Birth | New Orleans,Louisiana, United States |
| Email Address: | teamdewhit@gmail.com | Home Address | PSC 558 BOX 4466 FOP, AP 96375 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Catholic | Baptized: | YES |
| Local Public School System: | DODEA | Local Public School Child Would Attend: | na – moving from Japan |
| Race of the Student: | Black | Ethnicity of Student: | Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Julia Andrea Garcia Whitaker | Terry Leonard Whitaker |
| Maiden Name | Garcia | |
| Country of Birth | USA | USA |
| Home Address | PSC 559 BOX 4466 | PSC 558 BOX 4466 |
| Home Phone | ||
| Mother Cell Phone | (704) 891 8212 | (229) 449 6539 |
| Preferred Email | TEAMDEWHIT@GMAIL.COM | TEAMDEWHIT@GMAIL.COM |
| Mother Occupation | Nurse Practitioner | Lt COL |
| Employer | na | United States Marine Corps |
| Mother Work Phone | ||
| Religion | Catholic | Protestant |
| Parish/Church | Camp Foster Chapel | Camp Foster Chapel |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Trerry and Julia Whitaker | Country of Birth | |
| Home Address | PSC 558 BOX 4466 FPO, AP 96375 | Preferred Email | TEAMDEWHIT@GMAIL.COM |
| Home Phone | Cell Phone | (704) 891 8212 | |
| Occupation | Lt COL and Nurse Practitioner | Employer | United States Marine Corps |
| Work Phone | Religion | Catholic | |
| Parish/Church | Camp Foster Chapel | Person responsible for Tuition/Fee Payments: |
Terry Whitaker |
| Address, City, State, ZIP: | same as above | Phone & Email: | (229) 449 6539 |
Emergency Contact Information
| Contact #1: | Muhammad Rabb | Relation to Student: | Family Friend |
|---|---|---|---|
| Email Address: | romuhammad@gmail.com | Home Address: | 1309 E Street SE #38 WashingtON, D.C. 20003 United States |
| Home Phone | (404) 429 9740 | Other Phone | |
| Contact #2 | Muhammad Donique | Relation to Student: | Family Friend |
| Email Address | DONIQUE.NOBLES@gmail.oom | Home Address: | 1309 E Street SE #38 Washington, DC 20003 United States |
| Other Phone | (662) 312 7003 | Home Phone |
Student Background Information
| Does your child need any particular academic enrichment in order to be successful in school? | YES |
|---|---|
| If yes, please explain briefly (other forms will be required): |
Terry (Trip) has ADHD. While he has not had any academic complications, he does need to have the ability to move periodically and may need redirection. |
| 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? | YES |
| Please list: |
Trip will likely need flexible seating. |
| 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: | 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? | 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 30, 2022, August 30, 2021, September 1, 2018 | Zukeran Elementary, Milestones Academy, Montessori Children’s School | Okinawa, Jacksonville, NC, Jacksonville, NC | +81 098 9701019, 910-455-6928, 910-938-3826 | na |
For Catholic Applicants Only
| Current Parish: | Camp Foster Chapel | Pastor: | Fr. O’Malley |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | January 24, 2014 | All Saints Catholic Church | New Orleans | LA |
| Date Reconciliation: | ||||
| Date First Eucharist | May 11, 2022 | Camp Lejuene Chapel | Jacksonville | NC |
| 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 | Julia Whitaker |
| Father Names of Parents/Guardians | Terry Whitaker |
| Mother Signatures | Julia Whitaker |
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: |