Applicant Information
| Student Name: | Wilkins Ravena | Date | December 3, 1999 |
|---|---|---|---|
| Sex | Female | Place of Birth | Washington,DC, United States |
| Email Address: | wilkinsravena@yahoo.com | Home Address | 1399 13th St., N.W. Washington, DC 20009 |
| Siblings | Jessica Wilkins | [] | |
| Name | Jessica Wilkins | Grade | 2nd Grade |
| Religion: | Catholic | Baptized: | YES |
| Local Public School System: | PGCPS | Local Public School Child Would Attend: | Riverdale Elementary School |
| Race of the Student: | Two or more races | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Lisbern Wilkins | Raven Wilkins Sr. |
| Maiden Name | Maya | |
| Country of Birth | USA | USA |
| Home Address | 1399 13th St., N.W. | 1399 13th St., N.W. |
| Home Phone | (202) 333 1399 | (202) 333 1399 |
| Mother Cell Phone | (202) 210 1484 | (202) 210 1485 |
| Preferred Email | wilkinslisbern99@yahoo.com | bigpappa99@yahoo.com |
| Mother Occupation | Teacher | Principal |
| Employer | DBCR | ADW |
| Mother Work Phone | (301) 891 1300 | (301) 774 1399 |
| Religion | Catholic | Catholic |
| Parish/Church | St. Augustine | St. Augustine |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| 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: | Smith James | Relation to Student: | Uncle |
|---|---|---|---|
| Email Address: | jamessmill66@gmail.com | Home Address: | 1399 13th St., N.W. Washington, DC 20009 United States |
| Home Phone | (202) 444 1499 | Other Phone | |
| Contact #2 | Smith Martha | Relation to Student: | Aunt |
| Email Address | marthasmith99@gmail.com | Home Address: | 1399 13th St., N.W. Washington, DC 20009 United States |
| 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? | 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 | Non-Refundable Application Fee of $375.00 |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | |
| Mother Names of Parents/Guardians | Lisbern Wilkins |
| Father Names of Parents/Guardians | Raven Wilkins |
| Mother Signatures | Lisbern Wilkins |
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: |