Details – Catholic Schools

Applicant Information

Student Name:	Tchiwanou Marie-Liv	Date	April 24, 2017
Sex	Female	Place of Birth	Copenhagen,Denmark, Denmark
Email Address:	alidofr@yahoo.fr	Home Address	2124 Kalorama Rd NW, Washington, DC 20008 Maryland, United States
Siblings	Marie-Liv		[]
Name	Marie-Liv	Grade	4th
Religion:	Catholic	Baptized:	YES
Local Public School System:		Local Public School Child Would Attend:
Race of the Student:		Ethnicity of Student:

Family Information

	Mother	Father
Full Name
Maiden Name
Country of Birth
Home Address
Home Phone
Mother Cell Phone
Preferred Email
Mother Occupation
Employer
Mother Work Phone
Religion
Parish/Church

Parents’ Marital Status:		Student lives with:
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:		Relation to Student:
Email Address:		Home Address:
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?	YES
If yes, please explain briefly (other forms will be required):	Marie-Liv was educated in a French educational system
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:
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	Non-Refundable Application Fee of $375.00, Copy of Valid Age Birth Certificate, Acknowledgment and All Attachments(Required for Admission)
TRANSFER STUDENT APPLICANTS ONLY
Mother Names of Parents/Guardians	Pascal
Father Names of Parents/Guardians	Tchiwanou
Mother Signatures	Alice

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: