Details – Catholic Schools

Applicant Information

Student Name:	ayele kidus	Date	May 29, 0027
Sex	Male	Place of Birth	Wshington,DC, United States
Email Address:	bitew.chalie@yahoo.com	Home Address	, , , , , 3500 14st NW apt 402 Washington,DC
Siblings			[]
Name		Grade
Religion:		Baptized:
Local Public School System:		Local Public School Child Would Attend:
Race of the Student:	Black	Ethnicity of Student:	Non-Hispanic

Family Information

	Mother	Father
Full Name	Tirualem	chalie
Maiden Name	Ashenafi	bitew
Country of Birth	03/25/1993	04/09/1988
Home Address	3500 14st NW apt 402 WAshington,DC	3500 14st NW apt 402 Washington,DC
Home Phone
Mother Cell Phone
Preferred Email		bitew.chalie@yahoo.com
Mother Occupation	Home health aides	write know student
Employer	premier home health care
Mother Work Phone
Religion	Orhodox
Parish/Church

Parents’ Marital Status:	Single	Student lives with:	Mother and Father
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:	bitew chalie	Relation to Student:	son
Email Address:	bitew.chalie@yahoo.com	Home Address:	, , , , , 3500 14st NW washington,DC Apt 402
Home Phone		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)?	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
Physical Disability:	No existing physical disability
Learning Disorder:	No known learning disorder

Home Language Survey

Primary language(s) spoken in students household:	Amharic and English
Does primary guardian speak English?	YES
Is the Student Bi-Lingual?	YES
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:		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	Tirualem Ashenafi
Father Names of Parents/Guardians	chalie bitew
Mother Signatures	tirualem ashinafi

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: