Applicant Information
| Student Name: | Parson Krisden | Date | August 17, 2015 |
|---|---|---|---|
| Sex | Female | Place of Birth | WASHINGTON,DC, United States |
| Email Address: | debbieborum25@gmail.com | Home Address | 116 T ST NE Apt 309 Washington, DC 20002 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Baptized: | YES | |
| Local Public School System: | Local Public School Child Would Attend: | ||
| Race of the Student: | Black | Ethnicity of Student: |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Debbie Borum | Christopher Parson |
| Maiden Name | ||
| Country of Birth | United States | DC |
| Home Address | 116 T ST NE | Apt 309 |
| Home Phone | (202) 644 2565 | |
| Mother Cell Phone | (202) 644 2565 | |
| Preferred Email | debbieborum25@gmail.com | debbieborum25@gmail.com |
| Mother Occupation | Traffic Control Officer | |
| Employer | Department of Transportation | |
| Mother Work Phone | (202) 848 3247 | |
| Religion | ||
| Parish/Church | Temple of Praise |
| Parents’ Marital Status: | Single | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Debbie Borum | Country of Birth | United States |
| Home Address | 116 T ST NE | Preferred Email | debbieborum25@gmail.com |
| Home Phone | (202) 644 2565 | 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: | Borum Rosslyn | Relation to Student: | Grandmother |
|---|---|---|---|
| Email Address: | rosslyn01@gmail.com | Home Address: | 3506 RIVIERA ST TEMPLE HILLS, MD 20748 United States |
| Home Phone | (202) 644 2565 | 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? | YES |
| Please list: |
Krisden has a 504 plan in her current school due to her ADHD |
| 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: | 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 5, 2019 | Kipp Lead | Washington | 2026442565 |
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 | 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 | |
| Mother Names of Parents/Guardians | Debbie Borum |
| 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: |