Applicant Information
| Student Name: | Yoonis Ariam | Date | April 16, 2017 |
|---|---|---|---|
| Sex | Female | Place of Birth | Washington,DC, United States |
| Email Address: | helenabay0520@gmail.com | Home Address | 3023 14th st Nw 702 Washington, Dc 20009 United States |
| 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 | Eritrea | Somalia |
| Home Address | 3023 14th st Nw | Washington DC 2009 |
| Home Phone | ||
| Mother Cell Phone | (202) 509 6396 | (202) 704 8430 |
| Preferred Email | helenabay0520@gmail.com | helenabay0520@gmail.com |
| Mother Occupation | Store manager | |
| Employer | Exotic cafe | |
| 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 | Store manager | Employer | H&R LLC |
| Work Phone | (202) 229 9122 | Religion | Christian |
| Parish/Church | Person responsible for Tuition/Fee Payments: |
Serving our children | |
| Address, City, State, ZIP: | 1707 L street NW ste300 | Phone & Email: | (888) 329 6884 |
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) 121 3254 | |
| Contact #2 | Tesfaye Betelhem | 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)? | 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: | Tigrinya |
|---|---|
| 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 |
|---|---|---|---|---|
| Tubman Elementary Schoole | Washington | 2026737285 | Kindergarten |
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 | 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: |