Details – Catholic Schools

Applicant Information

Student Name:	Murray William	Date	June 23, 1999
Sex	Male	Place of Birth	Washington,DC, United States
Email Address:	bmurray@saintaugustine-dc.org	Home Address	5706 Fort Sumner Dr. Bethesda, MD 20816 United States
Siblings			[]
Name		Grade
Religion:	Catholic	Baptized:	YES
Local Public School System:	DCPS	Local Public School Child Would Attend:	Bancroft Elementary School
Race of the Student:	Black	Ethnicity of Student:	Non-Hispanic

Family Information

	Mother	Father
Full Name	Jean Smith	Bruce Smith
Maiden Name	McNerney
Country of Birth	USA	USA
Home Address	5706 Fort Sumner Dr.	5706
Home Phone	310-220-2001	310-220-2011
Mother Cell Phone	312-444-3333	312-444-4332
Preferred Email	jeansmith@yahoo.com	brucesmith99@yahoo.com
Mother Occupation	Homemaker	Former Football Player
Employer	N/A	Me Inc.
Mother Work Phone
Religion	Catholic	Catholic
Parish/Church	St. Augustine	St. Augustine

Parents’ Marital Status:		Student lives with:	Mother and Father
Full Name	William Murray	Country of Birth	United States
Home Address	5706 Fort Sumner Dr.	Preferred Email	brucesmith99@yahoo.com
Home Phone	301-229-2110	Cell Phone	310-110-2222
Occupation	Yes	Employer	No
Work Phone	310-222-2222	Religion	Baptist
Parish/Church	First Ebeneezer	Person responsible for Tuition/Fee Payments:	Bruce Smith
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?	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?	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
January 1, 2012	Bancroft Elementary	Washington	999999	3.2

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
TRANSFER STUDENT APPLICANTS ONLY	Current standardized test scores plus the two previous years’ scores
Mother Names of Parents/Guardians	Davina Smith
Father Names of Parents/Guardians	Bruce Smith
Mother Signatures	Davina Smith

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: