Applicant Information
| Student Name: | MartinezVelasquez Matias | Date | October 12, 2019 |
|---|---|---|---|
| Sex | Male | Place of Birth | Silver spring,MD, United States |
| Email Address: | karla.v688@gmail.com | Home Address | 3121 Mt Pleasant st NW 55 Washington, Dc 20010 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Catholic | Baptized: | YES |
| Local Public School System: | Local Public School Child Would Attend: | ||
| Race of the Student: | White | Ethnicity of Student: | Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Karla | Velasquez |
| Maiden Name | El Salvador | |
| Country of Birth | San Salvador | El Salvador |
| Home Address | 3121 MOUNT PLEASANT STREET NW | 55 |
| Home Phone | (202) 641 3640 | |
| Mother Cell Phone | (202) 641 3640 | |
| Preferred Email | karla.v688@gmail.com | |
| Mother Occupation | Surgical coordinator | Childrens Hospital |
| Employer | ||
| Mother Work Phone | (202) 476 5117 | |
| Religion | Catholic | |
| Parish/Church | Our lady of sorrows |
| Parents’ Marital Status: | Single | 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: |
Karla | |
| Address, City, State, ZIP: | 3121 MOUNT PLEASANT STREET NW | Phone & Email: | (202) 641 3640 |
Emergency Contact Information
| Contact #1: | Centeno Yolanda | Relation to Student: | Grandmother |
|---|---|---|---|
| Email Address: | Home Address: | ||
| Home Phone | (202) 420 9978 | Other Phone | |
| Contact #2 | Martinez Vanessa | Relation to Student: | Aunt |
| Email Address | Home Address: | ||
| Other Phone | Home Phone | (202) 336 4907 |
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: | Spanish |
|---|---|
| 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: | Our lady of sorrows | Pastor: | Father Foggo |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | January 1, 2015 | |||
| 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), Copy of Baptismal Certificate (Catholics only) |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | |
| Mother Names of Parents/Guardians | Karla |
| Father Names of Parents/Guardians | Velasquez |
| Mother Signatures | Karla Velasquez |
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: |