Details – Catholic Schools

Applicant Information

Student Name:	Zecarias Simon	Date	July 16, 2011
Sex	Male	Place of Birth	Washington,DC, United States
Email Address:	nikandsim@gmail.com	Home Address	4434 6th pl. NE , 20017
Siblings	Gelilah Zecarias, Salem Zecarias		[]
Name	Gelilah Zecarias, Salem Zecarias	Grade	3, 1
Religion:	Catholic	Baptized:	YES
Local Public School System:	Yes	Local Public School Child Would Attend:	CMI
Race of the Student:	Black	Ethnicity of Student:	Non-Hispanic

Family Information

	Mother	Father
Full Name	Azeb	Beraki
Maiden Name
Country of Birth	Ethiopia	DC
Home Address	4432 6th place. Ne
Home Phone
Mother Cell Phone	(240) 383 2138
Preferred Email	nikandsim@gmail.comn
Mother Occupation	Self employee
Employer
Mother Work Phone
Religion	Catholic
Parish/Church	St. Anthony/ St. Benedict The moore

Parents’ Marital Status:	Single	Student lives with:	Mother and Father
Full Name	Azeb Beraki	Country of Birth	Ethiopia
Home Address	4434 6th place ne	Preferred Email	nikandsim@gmail.com
Home Phone		Cell Phone	(240) 383 2138
Occupation	Self employed	Employer
Work Phone		Religion	Catholic
Parish/Church		Person responsible for Tuition/Fee Payments:
Address, City, State, ZIP:		Phone & Email:

Emergency Contact Information

Contact #1:	Michael Zecarias	Relation to Student:	Father
Email Address:	morgpy@yahoo.com	Home Address:	4527 7th Street Northeast Washington, DC 20017 United States
Home Phone	(301) 326 9663	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?	YES
If yes, please explain briefly (other forms will be required):	He has IEP
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:
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:	Tigrigna
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
	CMI	Washington DC	2403832138

For Catholic Applicants Only

Current Parish:	St. Anthony Padua	Pastor:	Father Fred

	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
Father Names of Parents/Guardians
Mother Signatures	Azeb Beraki

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: , :

PERSON RESPONSIBLE FOR TUITION/FEES PAYMENT

Name:		Address:
Phone Number:		NOTES: