Applicant Information
| Student Name: | Yoonis Kaled | Date | May 29, 2015 |
|---|---|---|---|
| Sex | Male | Place of Birth | Washington,Dc, United States |
| Email Address: | Helenabay0520@gmail.com | Home Address | 3023 14th st Nw 702 Washington, Dc 20009 |
| Siblings | [] | ||
| Name | Grade | ||
| Religion: | Christian | Baptized: | YES |
| Local Public School System: | Local Public School Child Would Attend: | TUBMAN | |
| Race of the Student: | Black | Ethnicity of Student: |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Helen gebremedhin | Yoonis Ahmed |
| Maiden Name | ||
| Country of Birth | Eritria | Somalia |
| Home Address | 3023 14 th st Nw #702 | Washington DC 20009 |
| Home Phone | ||
| Mother Cell Phone | (202) 509 6396 | |
| Preferred Email | helenabay0520@gmail.com | helenabay0520@gmail.com |
| Mother Occupation | ||
| Employer | Exotic caffe | |
| Mother Work Phone | ||
| Religion | Christian | |
| Parish/Church |
| Parents’ Marital Status: | Single | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Helen Gebremedhin | Country of Birth | Eritrea |
| Home Address | 3023 14th st Nw | Preferred Email | helenabay0520@gmail.com |
| Home Phone | Cell Phone | (202) 509 6396 | |
| Occupation | Stored manager | Employer | Exotic cafe |
| Work Phone | (202) 229 9122 | Religion | Christian |
| Parish/Church | Person responsible for Tuition/Fee Payments: |
Serving our children’s | |
| Address, City, State, ZIP: | 1707 L st Nw ste 300 Washington dc 20036 | Phone & Email: | (202) 464 6712 |
Emergency Contact Information
| Contact #1: | Gebrewold Saba | Relation to Student: | Friend |
|---|---|---|---|
| Email Address: | Home Address: | 9649 Hurst borne Road Columbia, MD 21046 United States |
|
| Home Phone | Other Phone | (301) 213 2548 | |
| Contact #2 | Tesfaye Betelihem | Relation to Student: | Friend |
| Email Address | Home Address: | 1816 metzerott rd Adelphi, Md 20783 United States |
|
| Other Phone | (240) 416 1097 | 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)? | YES |
| Briefly describe the type of service, length of service, and if it discontinued, a reason for discontinuation: |
Speech |
| 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: | Tigirnya |
|---|---|
| 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)? | 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 | |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | |
| Mother Names of Parents/Guardians | Helen gebremedhin |
| Father Names of Parents/Guardians | |
| Mother Signatures | Helen gebremedhin |
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: |