Details – Catholic Schools

Applicant Information

Student Name:	Ordonez Sergio I	Date	November 10, 2011
Sex	Female	Place of Birth	Washingto,DC, United States
Email Address:	abreumartha75@gmail.com	Home Address	5502 D st se
Siblings			[]
Name		Grade
Religion:		Baptized:
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	Martha Abreu
Maiden Name	A
Country of Birth	Dominican Republic
Home Address	5502 D st se
Home Phone
Mother Cell Phone
Preferred Email	abreumartha75@gmail.com
Mother Occupation	Operations Coordinator
Employer	Sitar Arts center
Mother Work Phone
Religion
Parish/Church

Parents’ Marital Status:		Student lives with:	Mother Only
Full Name	Martha	Country of Birth	Dominican Republic
Home Address	5502 D st se	Preferred Email	abreumartha75@gmail.com
Home Phone		Cell Phone
Occupation	Operations Coordinator	Employer	Sitar Arts Center
Work Phone		Religion
Parish/Church		Person responsible for Tuition/Fee Payments:	Martha Abreu
Address, City, State, ZIP:		Phone & Email:

Emergency Contact Information

Contact #1:	Ordonez Sergio V	Relation to Student:	Father
Email Address:		Home Address:	2601 Douglas rd se apt.101 Washington DC 20020
Home Phone		Other Phone
Contact #2	Soriano Gisela	Relation to Student:	Grandmother
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?	YES
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:
Does your child need accommodations to be successful in school?	YES
Please list:
Does your child have any diagnosed allergies?	YES
If yes, please list (other forms will be required):
Will your child require medication to be administered during the school day?	YES
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:
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)?	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	Martha Abreu
Father Names of Parents/Guardians
Mother Signatures	Martha Abreu

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: