Applicant Information
| Student Name: | Habtu Bethanya | Date | November 20, 2009 |
|---|---|---|---|
| Sex | Female | Place of Birth | Washington,DC, United States |
| Email Address: | henokhabtu72@gmail.com | Home Address | 1350 Clifton ST NW, 304W Washington, DC 20009 United States |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Orthodox Christian | Baptized: | YES |
| Local Public School System: | DCPCS | Local Public School Child Would Attend: | E.L. Haynes Public Charter School |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Konjit Gizaw | Henok Habtu |
| Maiden Name | ||
| Country of Birth | Ethiopia | Ethiopia |
| Home Address | 1350 Clifton ST NW, 304W | 1350 Clifton ST NW, 304W |
| Home Phone | (240) 423 9864 | (240) 423 9914 |
| Mother Cell Phone | (240) 423 9864 | (240) 423 9914 |
| Preferred Email | koni_m_2002@yahoo.com | henokhabtu72@gmail.com |
| Mother Occupation | Patient Care Technician | Taxi driver |
| Employer | Washington Hospital Center | Self-employed |
| Mother Work Phone | (202) 877 3169 | (240) 423 9914 |
| Religion | Orthodox Christian | Orthodox Christian |
| Parish/Church | St. Mary Church | St. Mary Church |
| 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: | Teklu Altashwork | Relation to Student: | God mother |
|---|---|---|---|
| Email Address: | Home Address: | 1312 Clifton ST NW, 104S Washington, DC 20009 United States |
|
| Home Phone | (202) 341 3862 | 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: | Amharic |
|---|---|
| Does primary guardian speak English? | YES |
| Is the Student Bi-Lingual? | YES |
| 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 |
|---|---|---|---|---|
| August 4, 2015 | E.L. Haynes | Washington | 2026674446 | 2.8 |
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, Archdiocese of Washington Immunization Policy, Acknowledgment and All Attachments(Required for Admission), Copy of Baptismal Certificate (Catholics only), Allergy Action Plan (If Applicable), Copy of custody order, or other applicable court orders (If Applicable), All relevant evaluations/assessments and previous special education plans (If Applicable) |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | Current standardized test scores plus the two previous years’ scores, Current report card including comments and the two previous years’ report cards |
| Mother Names of Parents/Guardians | Konjit Gizaw |
| Father Names of Parents/Guardians | Henok Habtu |
| Mother Signatures | Konjit Gizaw |
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: |