Applicant Information
| Student Name: | Danielle Elisma | Date | April 29, 2019 |
|---|---|---|---|
| Sex | Female | Place of Birth | Winston Salem,NC, United States |
| Email Address: | boldselismafamily@gmail.com | Home Address | 5155 King Charles Way Bethesda, MD 20814 United States |
| Siblings | [] | ||
| Name | Grade | Pre-K 4 | |
| Religion: | Christian | Baptized: | YES |
| Local Public School System: | Attends Little Group at Our Lady of Lourdes Bethesda, MD | Local Public School Child Would Attend: | Montgomery Co |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Letitia Bolds Elisma | Denmarc Elisma |
| Maiden Name | Bolds | |
| Country of Birth | United States | Haiti |
| Home Address | 5155 King Charles Way | |
| Home Phone | (843) 991 6142 | (336) 312 3758 |
| Mother Cell Phone | ||
| Preferred Email | letitia.bolds@gmail.com | boldselismafamily@gmail.com |
| Mother Occupation | Physician | Engineer/PhD Candidate |
| Employer | DoD ATA MMC | Howard University |
| Mother Work Phone | ||
| Religion | Chrisitian | Catholic |
| Parish/Church |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Letitia Bolds Elisma | Country of Birth | United States |
| Home Address | 5155 King Charles Way | Preferred Email | letitia.bolds@gmail.com |
| Home Phone | (843) 991 6142 | Cell Phone | |
| Occupation | Physician | Employer | DoD |
| Work Phone | Religion | Christian | |
| Parish/Church | Person responsible for Tuition/Fee Payments: |
Letitia Bolds Elisma | |
| Address, City, State, ZIP: | 5155 King Charles Way | Phone & Email: | (843) 991 6142 |
Emergency Contact Information
| Contact #1: | Malik Bolds | Relation to Student: | Maternal Uncle |
|---|---|---|---|
| Email Address: | malikbolds0@gmail.com | Home Address: | 12201 King Arrow St Bowie, MD 20207 United States |
| Home Phone | (301) 543 0897 | Other Phone | |
| Contact #2 | Mary Bolds | Relation to Student: | Maternal Grandmother |
| Email Address | Home Address: | ||
| Other Phone | (240) 505 2223 | 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, French |
|---|---|
| Does primary guardian speak English? | YES |
| Is the Student Bi-Lingual? | NO |
| Does the student spend significant time with a non-English speaking caregiver? | YES |
Transferring Students
| Is the student transferring from another school(s)? | YES |
|---|
| Dates Attended | School Name | City | Phone Number | Grade Avg |
|---|---|---|---|---|
| September 5, 2022 | Our Lady Of Lourdes | Bethesda |
For Catholic Applicants Only
| Current Parish: | Our Lady of Lourdes | Pastor: | Fr. Rob Walsh |
|---|
| Date | Church | City | State | |
|---|---|---|---|---|
| Baptism | August 24, 2019 | Our Lady of Mercy | Winston Salem | NC |
| 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 | Letitia Bolds Elisma |
| Father Names of Parents/Guardians | Denmarc Elisma |
| Mother Signatures | Letitia Bolds Elisma |
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: |