Applicant Information
| Student Name: | marciane Guilmard | Date | February 8, 2011 |
|---|---|---|---|
| Sex | Female | Place of Birth | Lages,SC, United States |
| Email Address: | sguilmard@yahoo.com | Home Address | 720 Girard Street NW Washington, DC 20001 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Baptized: | YES | |
| Local Public School System: | Basis PCS | Local Public School Child Would Attend: | CHEC |
| Race of the Student: | Two or more races | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Luciane Barreto Guilmard | Sebastien Boris Guilmard |
| Maiden Name | Guimaraes | |
| Country of Birth | brazil | USA |
| Home Address | 720 GIrard street nw | 720 GIrard street nw |
| Home Phone | (202) 290 2929 | (202) 290 2929 |
| Mother Cell Phone | (202) 701 0012 | (202) 320 2020 |
| Preferred Email | lucydesol@gmail.com | sguilmard@yahoo.com |
| Mother Occupation | Personal trainer | architect |
| Employer | Vida Fitness | EPA |
| Mother Work Phone | (202) 564 6430 | |
| Religion | Methodist | Catholic |
| Parish/Church | District Church | District Church |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Marciane Barreto | Country of Birth | United States |
| Home Address | 720 Girard Street NW | Preferred Email | |
| Home Phone | (202) 290 2929 | Cell Phone | |
| Occupation | Employer | ||
| Work Phone | Religion | ||
| Parish/Church | District Church | Person responsible for Tuition/Fee Payments: |
Sebastien Guilmard |
| Address, City, State, ZIP: | 20001 | Phone & Email: | (202) 320 2020 |
Emergency Contact Information
| Contact #1: | guilmard patrice | Relation to Student: | grandfather |
|---|---|---|---|
| Email Address: | patriceguilmard@gmail.com | Home Address: | 1426 colleen lane mclean, va 22101 United States |
| Home Phone | (703) 893 4046 | Other Phone | (202) 431 9955 |
| Contact #2 | Martorana Paul | Relation to Student: | Friend of family |
| 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? | |
|---|---|
| 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)? | frm_half |
| 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? | |
| Please list: | |
| Does your child have any diagnosed allergies? | |
| If yes, please list (other forms will be required): | |
| Will your child require medication to be administered during the school day? | |
| If yes, please explain briefly (other forms will be required): | |
| Medical Diagnosis: Please check ✓ all that apply: | |
| Physical Disability: | |
| Learning Disorder: |
Home Language Survey
| Primary language(s) spoken in students household: | |
|---|---|
| Does primary guardian speak English? | |
| Is the Student Bi-Lingual? | |
| Does the student spend significant time with a non-English speaking caregiver? |
Transferring Students
| Is the student transferring from another school(s)? |
|---|
| 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 | |
| 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: |