Applicant Information
| Student Name: | Kasa Hendeke | Date | September 7, 2018 |
|---|---|---|---|
| Sex | Female | Place of Birth | Washington,DC, United States |
| Email Address: | mbachoro@gmail.com | Home Address | 2900 14th ST NW Apt# 706 Washington DC, DC 20009 United States |
| Siblings | Maba Kasa | [] | |
| Name | Maba Kasa | Grade | 5th |
| Religion: | Baptized: | YES | |
| Local Public School System: | Centralia | Local Public School Child Would Attend: | Tubman elementary school |
| Race of the Student: | Black | Ethnicity of Student: | Non-Hispanic |
Family Information
| Mother | Father | |
|---|---|---|
| Full Name | Tigist Tumoro | Mulatu Bachoro |
| Maiden Name | Damise | Kasa |
| Country of Birth | Ethiopia | Ethiopia |
| Home Address | 2900 14th ST NW Washington, Apt# 706 DC 20009 | 2900 14th ST NW Washington, DC 20009 apt# 706 |
| Home Phone | (120) 239 3977 | (120) 272 5128 |
| Mother Cell Phone | ||
| Preferred Email | mbachoro@gmail.com | mbachoro@gmail.com |
| Mother Occupation | no | patent Examiner |
| Employer | USPTO | |
| Mother Work Phone | (202) 725 1282 | |
| Religion | Christin | |
| Parish/Church | Ethiopian, Evangelical Church |
| Parents’ Marital Status: | Married | Student lives with: | Mother and Father |
|---|---|---|---|
| Full Name | Mulatu kasa Bachoro | Country of Birth | United States |
| Home Address | 2900 14th ST NW Washington, DC 20009 | Preferred Email | mbachoro@gmail.com |
| Home Phone | (120) 290 2351 | Cell Phone | (202) 902 3519 |
| Occupation | Employer | ||
| Work Phone | Religion | ||
| Parish/Church | Person responsible for Tuition/Fee Payments: |
||
| Address, City, State, ZIP: | Phone & Email: |
Emergency Contact Information
| Contact #1: | Delebo Tsegaye | Relation to Student: | Friend |
|---|---|---|---|
| Email Address: | tsedelebo11@gmail.com | Home Address: | 1307 Columbia Road N.W. Apt 102 Apt#102 Washington DC, DC 20009 United States |
| Home Phone | (202) 600 5361 | Other Phone | (202) 600 5361 |
| Contact #2 | Hagos Gebrezgi | Relation to Student: | Friend |
| Email Address | gghagos2@gmail.com | Home Address: | 2900 14th ST NW Washington, DC 20009 Apt# 221 Washington DC, DC 20009 United States |
| Other Phone | (202) 386 8181 | Home Phone | (202) 386 8181 |
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? | YES |
Transferring Students
| Is the student transferring from another school(s)? | YES |
|---|
| Dates Attended | School Name | City | Phone Number | Grade Avg |
|---|---|---|---|---|
| September 1, 2022 | Centronia | Washington DC | 2023324200 | NA |
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), Allergy Action Plan (If Applicable) |
|---|---|
| TRANSFER STUDENT APPLICANTS ONLY | Current standardized test scores plus the two previous years’ scores |
| Mother Names of Parents/Guardians | Tigist Tumoro |
| Father Names of Parents/Guardians | Mulatu Bachoro |
| Mother Signatures | T.T |
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: |