APLIKASYON POU ABÒNMAN JENN TIMOUN NAN BOYS & GIRLS CLUBS nan BOSTON (BGCB)
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- Edwin Kennedy
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1 Dat la: APLIKASYON POU ABÒNMAN JENN TIMOUN NAN BOYS & GIRLS CLUBS nan BOSTON (BGCB) Byenveni nan Klib la! N ap kenbe tout enfòmasyon ki anba la yo konfidansyèl. Nou pa fè diskriminasyon kont akòz kantite lajan yo genyen, ras yo, si yo andikape, oryantasyon seksyèl yo, ak sèks yo. Nou vize pou fè nenpòt aranjman rezonab oswa bay nenpòt sipò pou manm nou yo ki pral garanti yo reyisi nan Klib la. Kèk nan enfòmasyon nou mande yo ede nou kenbe pri abònman yo ba ak bon mache. Tanpri ekri repons yo klè! Klib la(tcheke youn): Blue Hill (Dorchester) Charlestown Chelsea (Jordan) Condon Franklin Hill Hennigan Mattapan Orchard Gardens South Boston Sumner Yawkey (Roxbury) Sèlman Manm Frè resevwa Kalite Abònman (Tcheke youn): Nouvo Abònman Renouvèlman Abònman Dat la: Nimewo Manm Oryantasyon an te Fèt: Wi / Non Prèv Laj: Wi / Non Prenon Manm Nan: Non Fanmi li: Dat Nesans: / / Laj: Sèks: Gason Fi Pou tout timoun ki gen sis (6) lane, n ap bezwen batistè yo ak prèv yo enskri nan klas premye ane. Tout enfòmasyon ki nan aplikasyon pou abònman nan ap rete konfidansyèl epi se sèlman anplwaye majè ki chwazi espesyalman pou sa k ap wè yo. Adrès: Vil: Kòd Postal: Telefòn selilè manm nan(si li gen plis pase 13 lane) Lekòl: Imèl manm nan (si li gen plis pase 13 lane) Kalite Lekòl: Piblik Koperativ Lekòl Prive Pwogram METCO Klas: Èske manm nan te nan klas a avan? Wi Non Èske frè oswa sè manm nan se manm Klib la oswa yo te manm deja? Wi Non Èske manm nan nan yon fwaye dakèy oswa se yon fanmi li k ap okipe li? Wi Non Èske manm nan te nan yon lòt Klib/Program BGCB deja?: Yawkey Jordan Orchard Gardens Blue Hill Sumner Hennigan South Boston Franklin Hill Mattapan Charlestown Condon Kijan pitit ou pral fè pou li rantre lakay li lè li soti nan Klib la? (Tcheke tout sa ki aplike) Mache(pou timoun ki gen 10 lane oswa plis gade regleman konsènan timoun ki mache yo) Yon moun majè ap vin chèche li lòt: ENFÒMASYON KONSÈNAN PARAN/RESPONSAB LEGAL Relasyon ak Manm nan (ansèkle) Manman Pap Bòpè/Bèlmè Tant/Tonton Sè Frè Kouzen/Kouzin Granparan Paran Fanmi Dakèy Lòt Non Adrès Relasyon ak Manm nan (ansèkle) Manman Pap Bòpè/Bèlmè Tant/Tonton Sè Frè Kouzen/Kouzin Granparan Paran Fanmi Dakèy Lòt Non Adrès Vil: Kòd Postal: Vil: Kòd Postal: Telefòn Selilè Telefòn Selilè Telefòn Travay Adrès Imèl Telefòn Travay Adrès Imèl 1
2 ENFÒMASYON MOUN POU KONTAKTE SI GEN YON IJANS De (2) moun nou ka kontakte si nou pa ja jwenn ou. Ou pa ka mete non pa ou. Èske ou otorize moun sa a pou li vin pran manm nan? Wi Non Non: Sa li ye pou Manm nan (ansèkle) Tant/Tonton Sè Frè Kouzen/Kouzin Granparan Zanmi Fanmi an Lòt Telefòn Selilè: Telefòn Travay: Èske ou otorize moun sa a pou li vin pran manm nan? Wi Non Non: Sa li ye pou Manm nan (ansèkle) Tant/Tonton Sè Frè Kouzen/Kouzin Granparan Zanmi Fanmi an Lòt: Telefòn Selilè: Telefòn Travay: Enfòmasyon pou Kontak Medikal Konpayi Asirans Sante: Mass Health Tufts Harvard Pilgrim Fallon Community Health Blue Cross/Blue Shield Neighborhood Health Other Non mèt kontra asirans la Non doktè Premye Swen an Nimewo telefòn doktè a Nimewo Kontra Asirans la Pwoblèm Medikal Tanpri tcheke la a si pitit ou pa gen okenn pwoblèm medikal ou konnen. (Klike anba la a pou pwoblèm medikal yo.) Opresyon Dyabèt Pwoblèm pou Tande Avèg ADHD Otism Kriz Twoub Imè Èske pitit ou a gen yon pwoblèm medikal ou panse ki pral gen yon enpak sou tan li nan Klib la? Wi Non Si repons la se wi,, tanpri eksplike: Èske pitit ou sèvi ak yon EpiPen? Wi Non Èske pitit ou sèvi ak yon inalatè? Wi Non Èske pitit ou sèvi ak ensilin? Wi Non Èske pitit ou bay tèt li medikaman? Wi Non Si repons la se wi, ki medikaman pitit ou a pran? Lòt enfòmasyon medikal pou pataje avèk pèsonèl la: Alèji Tanpri tcheke la a si pitit ou pa gen okenn alèji ou konnen. (Klike anba la a pou alèji ou konnen yo.) Manje: Pistach Nwa Lèt / laktoz Frèz Soja Ble Pwazon/Fwidmè Ze Medikaman: Penisilin Aspirin Amoksisilin : man Abèy ki Pike Polèn Pousyè Mwezi Zèb Lòt: Latèks Pafen Krèm: Anviwon 2
3 Nou vize pou aprann tout sa ki posib sou manm nou yo pou nou ka fè nenpòt aranjman rezonab oswa bay nenpòt sipò pou manm nou yo ki pral garanti yo reyisi nan Klib la. Chak klib gen dwa pou deside si l ap aksepte yon nouvo manm selon resous ak kapasite etablisman yo a ak kantite manm pèsonèl yo genyen. Kisa ou swete pou pitit ou nan klib la? Kisa ki fòs pitit ou a? Tanpri endike si pitit si plis sipò nan nenpòt nan domèn sa yo te ka itil pitit ou a: Fizik Itilize / bezwen yon chèz woulant Itilize / bezwen aksè na asansè Kominikasyon Lang Siy Pa Vèbal Lòt zòn komen manm ka bezwen plis sipò: Tranzisyon pou soti nan yon aktivite a yon lòt Jere bagay ki estimile sans moun (tankou limyè oswa bwi) Swiv direksyon Kontwole fristrasyon Fè ak kenbe zanmi Kontwole kòlè ak lòt fristrasyon Jere eksperyans ak gwoup ki gen anpil moun Mande èd Lòt: Èske pitit ou resevwa sipò an plis nan lekòl la oswa nan kominote a? Plan Edikasyon Pèsonalize (IEP) : 504 (aranjman) Espesyalis pou Ede li Pale Rankontre ak Konseye Lekòl oswa Èske gen okenn pwofesyonèl ki konnen pitit ou a li te ka itil s nou pale ak li (tankou pwofesè, konseye, doktè)? Wi Non * Si se Wi, tanpri ale kote Travayè Sosyal Klib la pou siyen yon otorizasyon pou jwenn enfòmasyon. Èske gen okenn lòt bagay ou vle nou konnen? 3
4 ENFÒMASYON DEMOGRAFIK Repons ou anba a yo se rete KONFIDANSYÈL, epi yo enpòtan pou kote k ap finanse nou yo. Enfòmasyon sa yo pral ede nou jwenn don ak sibvansyon pou kenbe frè abònman yo pa. Tout enfòmasyon sa yo nesesè pou abònman. Mèsi! Revni Anyèl Kay la- Chwazi ran ki pi pre revni ou a $0 - $13,000 $27,001 $33,000 $46,001 $49,000 $59,001 $63,000 $73,001 $76,000 $86,001 $89,000 $13,001 $17,000 $33,001 $37,000 $49,001 $53,000 $63,001 $66,000 $76,001 $79,000 $89,001 $96,000 $17,001 $23, 000 $37,001 $43,000 $53,001 $56,000 $66,001 $69,000 $79,001 $83,000 $96,001 $103,000 $23,000 $27,000 $43,001 $46,000 $56,001 $59,000 $69,001 $73,000 $83,001 $86,000 $103,001 $113,000 $113,001 $123,000 Lòt: Ras (Tcheke Youn): Ameriken Nwa Azyatik Blan Ispanik/Latino Plizyè ras Awayen Natif / Abitan Pasifik Lan nou pale plis nan kay la: (tcheke youn) : Angle Mandarin Kreyòl Ayisyen franse Endou Vyetnamyen Pòtigè Kanbòdj Panyòl Kap Vèdyen Kijan Manm nan pale angle? Pa byen Pasab Trè byen Pwogram Mande Midi Lekòl (tcheke youn) Gratis Pri redwi Peye pou manje midi Èske Manm nan gen yon bon pou gadri? Wi Non Total # Moun nan Kay la (tcheke youn): oswa plis Man nan Viv pi Souvan ak (tcheke youn): Papa sèlman Granparan Manman sèlman Responsab legal Tou de paran Tonton Bòpè Tant Bèlmè Paran Fanmi Dakèy Sè: Konbyen? Frè: Konbyen? Kalite Lojman: Lwe Pwopriyete Lojman Piblik Ebèjman Ap viv ak fanmi Fwaye Dakèy San kay Kay Paran/Responsab Legal Selibatè? (tcheke youn) Wi Non Tou de paran yo gen dwa parantal Pwogram Asistans (Tcheke tout sa ki Sekirite Sosyal Medicaid Konpansasyon Vetran TANF (Èd Tanporè Pou Fanmi ki Nan Bezwen) WIC (Fanm Tibebe ak Timoun) 4
5 KONSANTMAN: tanpri ansèkle Wi oswa Non epi mete insyal ou Ankèt ak Kesyonè Mwen, paran/responsab legal timoun minè non li sou aplikasyon sa a, bay pèmisyon pou BGCG mennen ankèt ak pitit men konsènan eksperyans ak konpòtman li nan Klib li a, konpetans ak atitid kote yo sèvi sak Bwat Zouti Mezi Rezilta Boys & Girls Clubs of America s (BGCA) oswa lòt materyèl ankèt. Mwen bay pèmisyon pou BGCB pataje enfòmasyon sou timoun non li sou aplikasyon sa a ak BGCA oswa lòt asosye pwogram nan pou zafè rechèch ak/oswa pou evalye si pwogram nan ap travay byen. Tout enfòmasyon nou pataje ap rete konfidansyèl epi n ap pataje yo ak enfòmasyon ki rete enfòmasyon ki ka idantifye timoun nan oswa y ap enfòmasyon an gwoup. (Wi / Non) Tanpri mete inisyal ou: Dokiman pou Relasyon Piblik Mwen, paran/responsab legal la bay pèmisyon pou timoun minè non li sou aplikasyon sa a gen foto ak/oswa non li nan jounal, bilten enfòmasyon, ak/oswa nenpòt dokiman pwomosyon pou BGCP, ansanm ak anrejistreman sou odyo oswa videyo ak pou itilize oswa distribye nan lòt piblikasyon BGCB, swa sou fòm elektwonik oswa lòt fòm, san yo pa bezwen notifye mwen. An plis, mwen dakò pou BGCB itilize foto, anrejistreman sou kasèt ak videyo ak lòt travay timoun minè mwen an te kreye pou fè piblisite. Mwen renonse tout dwa pou enspekte oswa apwouve nenpòt nan san yo ki anwo a yo ka itilize kounye a oswa pi devan, kit mwen konnen y ap itilize yo ou pa, epi mwen renonse nenpòt dwa pou jwen redevans oswa lòt kalite rekonpans ki soti ladan yo. (Wi / Non) Tanpri mete inisyal ou: RENONSIYASYON: tanpri siyen anba a Travay Orijinal- Mwen, paran oswa responsab legal timoun minè non li sou aplikasyon an, rekonèt, rekonèt, konprann, epi dakò pou nenpòt travay atistik patisipan ak manm ki nan aktivite nan yon klib oswa pwogram BGCB devlope, ak tout dwa, tit ak enterè ki gen ladan, tankou, men se pa sèlman, konpozisyon mizikal, lirik, anrejistreman ak lòt travay orijinal atistik oswa enfòmatik manm nan fè li menm oswa ansanm ak nenpòt lòt manm pèsonèl la oswa manm, oswa yon lòt fason (nou pral rele tout bagay sa yo "Travay" apre sa), se pwopriyete BGCB sèlman. Paran/responsab la ak manm nan oswa nenpòt moun pa gen dwa anpeche BGCB itilize li nan okenn fason oswa okenn rezon BGCB deside ak pwòp jijman pa li sèlman. Paran/responsab la ak manm nan reprezante epi garanti ni Travay la, oswa nenpòt pati oswa eleman ki ladan, pa vyole dwa okenn moun oswa enstitisyon nan okenn fason, epi li dwe pwoteje epi pa rann BGCB responsab pou okenn reklamasyon, aksyon, pèt, dega, jijman oswa responsablite ki se akòz vyòl sa a. Paran/responsabl legal la oswa manm nan pa gen okenn dwa pou mennen BGCB devan lajistis oswa chèche oswa fè yon tribinal pase li lòd oswa lòt konpansasyon ki gen rapò ak Travay la oswa nenpòt distribisyon oswa eksplwatasyon. Otorizasyon Paran- Mwen, paran/responsab legal timoun minè nan li sou aplikasyon an, pou tèt nou, eritye, ekzekitè ak administratè nou yo, otorize, renonse, ak retire sou BGCB, ak BGCA, reprezantan, siksesè, konpayi asirans, benefisyè oswa nenpòt lòt moun oswa enstitisyon ki asosye ak nenpòt nan Òganizasyon yo ki mansyone anwo a ak manm pèsonèl, direktè oswa benevòl, tout responsablite, reklamasyon, demand, oswa kòz aksyon pou nenpòt ak tout pèt, domaj, blesi oswa lanmò ak nenpòt reklamasyon pou domaj ki ta genyen paske yo te itilize etablisman ki se pwopriyete oswa ki sou kontwòl òganizasyon yo ki mansyone anwo a, oswa patisipasyon nan aktivite òganizasyon sa yo swa nan Klib oswa deyò. Si pitit mwen an te blese, oswa si li ta bezwen swen touswit epi yo pa ka jwenn mwen, mwen otorize manm pèsonèl BGCB yo pou siyen pou timoun minè non li sou aplikasyon an an ka jwen swen ijan. Divè- Mwen konprann Klib la pa yon gadri ki gen lisans pou sa, epi li pa janm deklare se sa li ye. (Sòf si pitit ou anrejistre nan Pwogram Gradin pou Timoun Laj Lekòl ki gen lisans la) Medikal - Si pitit mwen an te blese, oswa si li ta bezwen swen touswit epi nou pa ka jwenn mwen, mwen otorize anplwaye Boys & Girls Clubs of Boston yo pou siyen pou pitit mwen an ka jwen swen medikal touswit. Avètisman - Tout sa ki nan aplikasyon abònman sa a se verite epi mwen te itilize tout kapasite mwen pou ranpli li. Mwen bay pèmisyon pou timoun minè non li sou laplikasyon an nan vin yon manm BGCB. Mwen konprann Klib la pa responsab pou chòk pèsonèl oswa pwopriyete pèsonèl ki pèdi epi m ap responsab pou peye pou nenpòt bagay nan Klib la pitit mwen fè eskpre li domaje oswa kraze. Mwen konprann patisipasyon nan pwogram sa a pral lè mwen rekonèt mwen te resevwa gid pou paran BGCB a epi mwen fè yon angajman pou patisipe nan yon sesyon oryantasyon avan patisipasyon. Mwen konprann manm nan gen pou li respekte kòd kondwit la epi si pa fè sa yo ka anile abònman li nan Klib la. Otoriasyon ak Akò po pa Pote Plen nan Tribinal - Nan konsiderasyon pou pèmèt pitit mwen an patisipe nan aktivite Boys and Girls Clubs of Boston, Inc. founi, òganize, oswa patwone oswa afilye ak yo oswa konekte ak yo nan yon lòt manyè ("Aktivite" yo), mwen dakò pou pwoteje, egzanpte, pa rann responsab, toujou dakò pou pa mennen devan la jistis Boys and Girls Clubs of Boston ak nenpòt nan direktè, sipèvizè, ofisye, administratè, manm pèsonèl, ajan, afilye, siksesè ak moun li chwazi pou reprezante li yo, ak pou libere yo kont nenpòt ak tout responsablite pou nenpòt reklamasyon oswa pwosè devan tribinal ki se akoz patisipasyon pitit mwen an nan Aktivite yo kit Aktivite yo fèt lakay Boys and Girls Clubs of Boston oswa yon lòt kote. Siyati Paran/Responsab: *Depi ou siyen la ou konfime tout enfòmasyon yo ou bay anwo a se verite epi yo egzat. Dat la: 5
6 Fòm Pou Refize Aksè nan Pwogram Devlopman Kòm an Sante pou Paran/Responsab Legal manm ki gen 8 a 12 lane Chè Fanmi manm ki gen 8 a 12 lane, Se yon gran plezi pou nou fè ou konnen nou pral amelyore efò pou edikasyon sou lasante nan Klib nou an. Anba la a yon rezime sou nouvo pwogram nou pral ofri manm ki gen 8 a 12 lane yo sèlman Epi sonje, ou mèt kontakte nou si ou gen nenpòt kesyon. Pwogram Edikasyon sou Lasante pou timoun ki gen 8 a 12 lane Klib nou an konsidere pwomosyon sante ak edikasyon sou lasante se yon gwo priyorite. Nou vize pou ajoute sou efè y ap fè nan lekòl ak lakay pou ede timoun yo konprann ak adapte ak kwasans ak devlopman yo. Se poutèt sa, ekip edikasyon sante nou an, kote Enfimyè Diplome Sante Kominotè ak Direktè Mòdvi an Sante nou an ap dirije, pral enkòpore pwogram edikasyon ki apwopriye selon laj manm yo pou ede yo devlope bonjan relasyon, ede yo konprann kò yo k ap chanje, ak ankouraje fè bon chwa nan tout bagay ki gen pou wè ak lasante. Sijè yo pral genyen: Kwasans ak devlopman adolesan, tankou chanjman fizik, emosyonèl, ak sosyal ki genyen pandan yon timoun ap fòme Anatomi, lè timoun ap fòme, ijyèn, ak pwodwi pou règ (egzanp tankou kotèks, tanpon, elatriye) Idantifye, devlope, ak kenbe bon relasyon Kijan maladi kontajye (tankou VIH / SIDA pou timoun klas 6èm ane ak plis) pwopaje ak fason pou anpeche yo Kominikasyon efikas, respè pou tèt ou ak respè pou lòt moun Konprann ki jan ak ki lè pou w ale kote yon granmoun ou fè konfyans Dapre ekspè medikal yo, ti gason, epi sitou ti fi, ap devlope fizikman lè yo pi jèn. Anpil tifi ap kòmanse fòme depi lè yo gen 8 lane. Pliske anpil lekòl pa ka ofri kalite edikasyon sa yo paske yo pa gen ase rsous, BGCB ap kontan ajoute edikasyon nan domèn enpòtan sa a. Timoun yo pral amize yo nan pwogram pozitif sa a yon manm pèsonèl kalifye pral dirije pou abòde aspè fizik,,mantal, emosyonèl, sosyal devlopman adolesan yo nan yon nivo ki apwopriye pou laj yo. Pandan nou pral diskite ak pataje anpil pwodwi ijyèn (tankou chanpou, savon, pat dan, deyodoran, kotèks, tanpon), Klib la pral souliye sou se fanmi an ki pral deside ki pwodwi n ap itilize. Anplis, nan kèk ka, pwogram edikasyon pral gen seyans ki pou yon sèks espesifik kote ti gayon ak tifi yo pral patisipe separe pou asire manm yo alèz pou aprann bagay delika sayo. Chwa pou Paran/Responsab Legal Refize Manm ki gen 8 a 12 lane yo patisipe Si pitit ou a 6 oubyen 7 lane, ou pa bezwen ranpli fòm sa a. Si pitit ou gen ant 8 ak 12 lane epi ou PA vle li fè pati pwogram kò k ap devlope a, tanpri ranpli enfòmasyon sa yo epi retounen li nan Klib la. Si ou vle pitit ou yo resevwa edikasyon, ou pa bezwen ranpli oswa soumèt fòm sa a. Pou nenpòt kesyon oswa enkyetid, tanpri rele Enfimyè Diplome Klib nou an, Tricia McCarthy, nan or direksyon Klib la. Non Manm nan: Non Paran Gadyen an (ekri an lèt detache): Siyati Paran/Responsab Legal: Dat la: 6
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