Applicant Information
| Student Name: | Andrade Dominic | Date | August 23, 2013 |
|---|---|---|---|
| Sex | Male | Place of Birth | Washington,DC, United States |
| Email Address: | mauroandra@hotmail.com | Home Address | 842 Delafield st NE |
| 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 | Yapsis Palacios | Mauro Andrade |
| Maiden Name | ||
| Country of Birth | Colombia | Colombia |
| Home Address | 842 Delafield st NE | 842 Delafield st NE |
| Home Phone | (202) 714 6992 | (202) 681 1694 |
| Mother Cell Phone | ||
| Preferred Email | yazapaga@hotmail.com | mauroandra@hotmail.com |
| Mother Occupation | Data | Accountant |
| Employer | Mundo Verde | Global Vision and Development |
| Mother Work Phone | (202) 803 8967 | (240) 832 1694 |
| Religion | Washington, DC | Washington, DC |
| Parish/Church | Immaculate Conception | Immaculate Conception |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Mauro Andrade | Country of Birth | Colombia |
| Home Address | 842 Delafield st NE | Preferred Email | mauroandra@hotmail.com |
| Home Phone | (202) 681 1694 | Cell Phone | |
| Occupation | Accountant | Employer | Global Vision and Development |
| Work Phone | (240) 832 1694 | Religion | USA |
| Parish/Church | Immaculate Conception | Person responsible for Tuition/Fee Payments: |
Mauro Andrade |
| Address, City, State, ZIP: | 842 Delafield st NE | Phone & Email: | (202) 681 1694 |
Emergency Contact Information
| Contact #1: | Khadjibaeva Barno | Relation to Student: | Friend |
|---|---|---|---|
| Email Address: | barnok@hotmail.com | Home Address: | 4117 Fairfax St, Hyattsville, MD 20784 |
| Home Phone | (240) 605 3241 | Other Phone | |
| Contact #2 | Sinisterra Didier | Relation to Student: | Friend |
| Email Address | sinisterra.didier@gmail.com | Home Address: | 4613 B St SE, Washington DC 20019 |
| Other Phone | (202) 446 8784 | 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? | YES |
| If yes, please list (other forms will be required): |
Penut |
| 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? | YES |
| Does the student spend significant time with a non-English speaking caregiver? | YES |
Transferring Students
| Is the student transferring from another school(s)? | YES |
|---|
| Dates Attended | School Name | City | Phone Number | Grade Avg |
|---|---|---|---|---|
For Catholic Applicants Only
| Current Parish: | Immaculate Conception | Pastor: | Father Emilio |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | December 20, 2015 | Shrine of the Sacred Heart | Washington | DC |
| Date Reconciliation: | June 5, 2021 | Shrine of the Sacred Heart | Washington | DC |
| Date First Eucharist | June 5, 2021 | Shrine of the Sacred Heart | Washington | DC |
| Date Confirmation | June 6, 2026 | Shrine of the Sacred Heart | Washington | DC |
| 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) |
|---|---|
| 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 | Yapsis Palacios |
| Father Names of Parents/Guardians | Mauro Andrade |
| Mother Signatures | Yapsis Palacios |
For Office Use Only
| Check ✓and Date when each item is received and verified |
|---|
| Applicant Name: Andrade Dominic |
| 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: |