GO MIDDLEGO 中学

Re-Enrollment Form 2015-20162015-2016学年重新入学申请表

(Current 5th-7th Grade Students)（五至七年级）Requirements for Participation入学要求A year-round & year-to-year commitment is required for participation in the GO Project. This includes participation in GO Summer, our five-week full day program and GO School, our seven-month half-day Saturday academic program during the school year. 加入 GO Project 要求申请人年复一年的全年投入。这包括在学年内参加暑假为期五周的 GO Summer项目和为期七个月的周六学术项目。

Important Dates

March 28th , 20152014 年 3 月 28 日 Student Re-Enrollment Form 2015-2016, Report Card, GO Project

Student Evaluation Form, Updated IEP (if applicable) and Scholarship Application (optional) are DUE.以下手续截止：2015-2016 学生重新入学申请表，报告卡，GO Project 学生评估表，已更新的 IEP（如适用），奖学金申请（可选）

May/June (TBA)五月/六月（即将公布） Attend a Parent Orientation. Program Fees due.参加家长欢迎会。交纳项目费用。July 6th, 20152014 年 7 月 7 日 First day of the summer session (8:45 AM-5:00 PM).夏季学期开学（上午 9 点到下午 5 点）July 10th to July 12th, 20152014 年 7 月 10 日至 7 月12 日

Current 6th/Rising 7th Grade Leadership Camp -RAMAPO for Children现六年级/七年级学生领导能力锻炼夏令营-RAMAPO

August 7th, 20152014 年 8 月 7 日 LAST DAY OF GO SUMMER (*Half-Day: Dismissal at 12:30pm)

GO Summer结业（*半天：中午 12：30 解散）Re-Enrollment Process:重新入学手续：

The following documents must be submitted by the March 28th deadline in order for your re- enrollment to be completed. 为了完成您的从重新入学手续，您必须在 3 月 28 日前提交以下申请及文件。

Completed Student Re-Enrollment Form (ALL sections must be filled out).完整的学生重新入学申请表（全部填完）

Student Evaluation Form from your child’s classroom teacher (5th grade students only) 由您孩子学校老师填写的学生评价表（仅五年级学生）

Copy of Individual Education Plan (IEP) or Section 504 *if applicable. Only full IEPs will be accepted.

個別教育計劃 (IEP)的复印件或 第 504節（如适用）。只接受完整的 IEP

Copy of most recent report card and/or progress report. 最新报告卡和（或）进展报告的复印件 Copy of Promotion in Doubt (PID) letter from your child’s school*if applicable.您孩子学校提供的 留级警告信（Promotion in Doubt: PID）文件的复印件（如适用）

Fee and Scholarships: 费用和奖学金： There is a program fee of $80 for each student. The program fee can be paid by

check or money order and must be submitted during parent orientation.每个学生需交 80 美金的费用。这笔费用必须在家长欢迎会上以支票或汇票形式提交● Scholarships are available for families who qualify. 满足条件的家庭可以获得奖学金● The Scholarship Application must be submitted with the Student Application Form.奖学金申请表必须与学生申请表一道提交● Scholarship availability is based on the financial needs of our families and the scholarship funds

available to the GO Project. 奖学金发放情况取决去家庭经济需求和 GO Project 的奖学金来源● If you have applied for a scholarship, but have not received paperwork by the parent orientation

date, please bring attend your assigned orientation and speak to a GO Project staff member.如果您申请了奖学金，但在家长欢迎会前并未收到文书，请参加欢迎会并与 GO Project 的工作人员面谈。

Key Highlights of GO Middle Programming:GO 中学项目的亮点：

Teen Talk: Offered for all GO Middle students weekly. Teen talk provides an opportunity for our students to work on social skills and character development. Through their participation, they will develop greater self-awareness, self-confidence and healthier interpersonal relationships. 青少年谈话：每周提供给 GO 中学生。 该谈话能够帮助学生提高社交能力及性格发展。通过参与此活动，学生们能够提高自我意识，自信以及更健康的人际关系。Topics include, but are not limited to:

提供的话题有（但不限于）： Peer Relationships 同龄人际关系 Conflict Resolution 解决矛盾 Sexuality/Puberty 性欲/青春期 Personal Hygiene 个人卫生 Time management Decision Making 时间管理及做决定 Self-Esteem 自尊

* Topics will be discussed and explored with the students in a safe, age-appropriate, and educational space. 这些话题将会在一个舒适，年龄适应及教育的环境下进行。GO Bridges: GO Bridges provides a unique opportunity for our students to prepare for a successful transition to middle school and high school. Students will have the opportunity to discuss and express their excitement, anxieties, and concerns regarding the upcoming transition to middle/high school. They will participate in skills-based activities that focus on building self-confidence and readiness for this next phase of their academic careers. Parents/guardians will also participate in concurrent workshops to ensure comfort and familiarity with the choice process.GO Bridges：GO Bridges 为学生们提供了独一无二的机会去帮助学生更好的适应从初中到高中的过渡。学生将有机会分享与讨论他们在这过程中体验到的开心，焦虑与烦恼的事。他们将会参与一些能够提高自信的活动，同时也能够帮助他们适应以后的学术生活。家长/监护人们也将会参与到共同的活动。Leadership Camp (7th Grade Only): The Leadership Camp is a two-night, three day overnight camp. This camp will be facilitated in partnership with Ramapo for Children. Ramapo provides adventure-based, experiential learning experiences that promote positive character values, build social and learning competencies, and enhance self-esteem. The program is directed by highly experienced Ramapo facilitators and certified GO Teachers. The Leadership Camp will be held from July 10 th to July 12 th

(Friday to Sunday). The Leadership Camp is mandatory for all rising 7 th graders participating in GO Middle Summer Program. There is a mandatory GO Summer-Middle orientation for all parents. The orientation will provide information on GO Summer-Middle and the leadership camp. 领导能力锻炼夏令营（仅限七年级）：此夏令营为期三天两晚。它将与 Ramapo 合作。Ramapo 将提供基于冒险精神的学习经验，此经验能够促进积极的性格价值观，建立社交和学习能力，以及提高自尊心。这个项目将由富有经验的 Ramapo 工作人员和 GO 老师带领。 夏令营举行时间从 7月 10 日至 7 月 12 日（星期五至星期日）。所有即将成为七年级的并参加 GO 中学暑假项目的学生必须参加本夏令营。到时家长必须参加一个 GO 中学暑假项目的欢迎会。此会议将会讨论与 GO 中学暑假项目及夏令营的有关信息。

For more information, please contact the GO Project office at 212-533-3744 or via email at info@goprojectnyc.org如有疑问，请致电 GO办公室 212-533-3744 或邮件info@goprojectnyc.org

GO Project Re-Enrollment Form 2015-2016

2015-2016学年 GO Project重新录取表Please make sure to complete all the sections and submit this form with all required documents to:

The GO Project at 50 Cooper Square, New York, NY 10003 请确保全部完成，并将此表与其他所需文件一同交到：The GO Project, 50 Cooper Square, New York, NY 10003

Submission Due: Saturday, March 28th, 2016提交截止日期：2015年 3月 28日,星期一

Applicant Information:

申请人信息

Child’s First name (孩子的名字) _________________________ Last name (姓): ________________

Home Address (家庭住址): _____________________________________________ Apt (公寓号): __________

City (城市): ______________________________ State (州): ________ Zip Code (邮编): ___________

Home Phone (家庭电话): ___________________________________________________________

Mailing Address (if different)/ 邮寄地址 （如与家庭住址不一致）: ____________________________________ _

__________

Present Grade (年级): ________ Public School (公立学校): _____________________________

T-shirt Size (衬衫大小) ________

Is your child currently receiving free or reduced lunch in his/her public school?

您的孩子是否在学校享受免费或低价午餐？ Yes (是) No (否)

Parent/Caregiver Contact:家长/ 抚养人联系方式Mother/Guardian’s Name (母亲/ 监护人姓名): _______________________

Living with child (与孩子住在一起) Financially supporting child (经济上供应孩子)

Mobile Phone (手机): __________________________ Work Number (工作电话): ____________________

Email Address (电子邮件): __________________________________________________________

Is this person an emergency contact? (是不是紧急联系人？) Yes (是) No (否)

Currently employed? (有无工作？) Yes (是) No (否) Monthly salary (月收入): $____________

Preferred Language for Communication (Check All that Apply)/首选交流语言 （可多选）

Internal Use OnlyDate: ________________________[ ] Complete[ ] Incomplete

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English (英语) Spanish (西班牙语) Mandarin (中文普通话) Cantonese (中文粤语)

Other (其它):______________________

Father/ Guardian’s Name (父亲/监护人姓名): _________________________

Living with child (与孩子住在一起) Financially supporting child (经济上供应孩子)

Mobile Phone (手机): __________________________ Work Number (工作电话): ____________________

Email Address (电子邮件): __________________________________________________________

Is this person an emergency contact? (是不是紧急联系人？) Yes (是) No (否)

Currently employed? (有无工作？) Yes (是) No (否) Monthly salary (月收入): $____________

Preferred Language for Communication (Check All that Apply)/首选交流语言 （可多选）

English (英语) Spanish (西班牙语) Mandarin (中文普通话) Cantonese (中文粤语)

Other (其它):______________________

Annual Household income (required, documentation may be requested)/家庭年收入（需填，或许需要相关文件）:

Less than $14,999 (少于 14,999美金) $15,000-$19,999 (15,000至 19,999美金)

$20,000-$24,999 (20,000 至 24,999美金) $25,000-$29,999 (25,000至 29,999美金)

$30,000-$34,999 (30,000至 34,999美金) $35,000-$39,999 (35,999至 39,999美金)

$40,000-$44,999 (40,000至 44,999美金) $45,000-$49,999 (45,000 至 49,999美金)

$50,000- $54,999 (50,000至 54,999美金) $55,000-$59,999 (55,000至 59,999美金)

$60,000-$69,999 (60,000至 69,999美金) $70,000-$79,999 (70,000至 79,999美金)

$80,000-$89,999 (80,000至 89,999美金) $90,000 + (90,000美金以上)

Household Size:

家庭人数：

Single Parent Household (单亲家庭) Two-Parent Household (双亲家庭)

Number of people in the household (including you and your child) /家庭人数（包括您和您的孩子）: ___________

**********************************************************************************

The GO Middle Program allows your child to report to and be dismissed from the program site on

their own. In order to ensure your child’s safety, please complete the following questions.

GO 中学项目允许您的孩子自己做出退出项目的决定。为了您的孩子的安全，请填写以下问题。2

1) Is your child reporting to the program on his/her own?您的孩子是自己向项目报告的吗?

Yes (是) No (否)

IF Yes, please complete the authorization form included in this re-enrollment form.

如果是，请填写后面的授权表格。2) Do you allow your child to go home on his/her own during GO Summer?您是否允许您的孩子在暑假自己回家？ Yes (是) No (否)

3) IF APPLICABLE, do you authorize your GO Middle child to pick up his/her younger sibling also

enrolled at GO? 如适用，您是否允许您的在 GO 中学读书的孩子接他/她的在 GO读书的弟弟妹妹？

Yes (是) No (否)

Authorization Pick-Up/Emergency Contact:

授权接送人 / 紧急联系人： Please list three other emergency contacts (over the age of 16), who we can call if needed and who are able to pick

up your child from programming: 请列出三名紧急联系人（16岁以上），以便我们需要时电话联系，并可以接走您的孩子

1)___________________________________________________________________________________________

Name(姓名) Relationship(关系) Phone Number (电话)

2)___________________________________________________________________________________________

Name(姓名) Relationship(关系) Phone Number (电话)

3)___________________________________________________________________________________________

Name(姓名) Relationship(关系) Phone Number (电话)

Applicant Medical/Behavioral Health Information:

申请人医疗健康/行为健康信息：

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1 Please mark if your child has any of the following medical/behavioral health conditions/如您孩子有以下医疗/行为健康方面的情况，请您划选:

Vision (视力) Hearing (听力) Heart (心脏) Seizures (癫痫) Allergy (过敏)

Asthma (哮喘) ADHD/ADD (多动症) Other (其它): _____________________________

If Yes, Please specify (如有，请具体说明): ___________________________________________________________________

2 Does the condition noted above require special medical/health assistance? (上述情况是否需要特殊医疗/健康帮助？)

Yes (是) No (否)

If Yes, Please specify (如是，请具体说明): ________________________________________________________________________________________

3 Does your child take medication? (您的孩子是否用药？)

Yes (是) No (否)

If Yes, please name any medication your child takes (如是，请注明您孩子使用的药品): ________________________________________________________________________________________

4 Do any of the medications listed above require administration during the summer program hours (8:45am-5:00pm)? Please note, we are unable to administer medication during the school year Saturday program (9:30am-12:30pm). 在夏季项目期间（上午 8:45到下午 5点），上述药品是否需要监护？注意，我们无法在周六学术项目（上午9：30到中午12：30）提供此服务。

Yes (是) No (否)

Applicant Academic Information:申请人学术信息：a My child’s CURRENT classroom setting is (我孩子现在的授课类型是):

General Education (一般教育) ICT (Integrated Co-Teaching/教师合作教学） 12:1 12:1:1

Other (其它): _______________________________________

b My child receives special education services and has an Individualized Education Plan (IEP) or Section 504/

我的孩子接受特殊教育服务，并有個別教育計劃(IEP)或第 504節:

Yes (是) No (否)

If yes, my child currently has 如是，我孩子现在有

IEP(個別教育計劃) Section 504 (第 504節)

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If yes, please submit copy of your child’s full IEP or Section 504.

如是，请提交您孩子的完整 個別教育計劃 (IEP) 或 第 504節

If yes, my child receives(如是，我孩子接受)：

SETTS (特殊教育教师支援服务) speech & language therapy (语音和语言治疗)

counseling (心理輔導) occupational therapy (职业治疗)

physical therapy (理疗) 1:1 paraprofessional (behavior) /一对一辅助人员（行为）

1:1 paraprofessional (health)/一对一辅助人员（健康）

Behavioral Intervention Plan (BIP) /行爲介入計

Other (其它): _____________________

c My child receives English as a Second Language (ESL) services at school: 我孩子在学校接受英语作为第二语言

教育（ESL） Yes (是) No (否)

If yes, your child’s current ESL Level (如是，您孩子现在的ESL水平):

Beginner (初级) Intermediate (中级) Advanced (高级)If you are not sure, please obtain this information from your child’s teacher如您不确定，请询问您孩子的老师

d My child has repeated a grade: 我孩子曾留过级

Yes (是) No (否)

If Yes, what grade(s) and in what year(s)/如是，哪一级，哪一年: _______________________

e My child is currently Promotion in Doubt (PID) for this school year/我的孩子现在有 2014至 2015学年的

“留级警告信”（PID）:

Yes (是) No (否)

*If yes, please submit the PID notification letter from the school.

如是，请提交学校的 “留级警告信”通知书f Did you meet with your child’s public school teacher for parent-teacher conferences?

您是否有与您孩子的老师开过家长会？ Fall（秋季） Spring（春季） Both（都有） Neither （从无）I understand that GO Project is a year-round and year to year program. I am committed to my child’s participation in GO’s year-round program for the 2015-2016 academic year. I am committed to my child’s continued enrollment until he/she graduates the program in the summer following their 8th grade year.我明白GO Project是一个全年的、年复一年的项目。我承诺我孩子将会参加GO Project的2015-2016学年全年项目。我承诺我的孩子将持续参加此项目，直到他或她在八年级后的夏天毕业。Additionally, I understand that GO Project has a three absence policy and that my child cannot be

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SCHOLARSHIP APPLICATION (Optional)

奖学金申请（可选）

Are there current financial hardships that are affecting your ability to pay the Program Fee? If so, please briefly explain and attach the appropriate documentation to support your response.

目前您是否有紧急困难，难以支付项目费用？若有，请简单解释并附上相关文件为证。 _______________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

You can request an amount from a full scholarship ($0) to $60 for financial aid to reduce the cost of the Program Fee for your child. 您可以申请全奖（0 到 60 美金）的经济援助，以降低您孩子的项目费用。Request Amount (申请金额): $___________

Before you submit, please check the following documents are prepared:

在您提交前，请您核对以下文件：

Application Check List:申请清单：

Completed Student Enrollment Form (ALL sections must be filled out.).完成学生入学申请表（完成全部）

Student Evaluation from your child’s public school teacher.

I understand that GO Project is a year-round and year to year program. I am committed to my child’s participation in GO’s year-round program for the 2015-2016 academic year. I am committed to my child’s continued enrollment until he/she graduates the program in the summer following their 8th grade year.我明白GO Project是一个全年的、年复一年的项目。我承诺我孩子将会参加GO Project的2015-2016学年全年项目。我承诺我的孩子将持续参加此项目，直到他或她在八年级后的夏天毕业。Additionally, I understand that GO Project has a three absence policy and that my child cannot be

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来自您孩子公立学校老师的学生评价表Copy of Individual Education Plan (IEP) and/or Section 504

*if applicable. Only full IEP will be accepted. 個別教育計劃（IEP）的复印件和/或 第 504節 注：如适用，只接受完整的 IEP文件。 Copy of most recent report card and/or progress report.最新的报告卡和/或进展报告的复印件

Copy of Promotion in Doubt (PID) letter from your child’s school *if applicable. 留级警告信（PID）的复印件 *如适用

GO Middle Student Independent Arrival/ Dismissal Authorization Form

GO 中学生独自到校或离校授权表

Student Name 学生姓名: _________________ Date of Birth出生日期: _________________

Parent Name 家长姓名: __________________________

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Parent/Guardian Authorization:家长 / 监护人授权： I give permission for my child to arrive to the program on his/her own and to be dismissed without me or an authorized picker upper present. He/she is responsible for leaving the program site independently at dismissal. 我允许我的孩子自己到达学校以及离校。他/她将对自己离校负责。My GO Middle Child is authorized to arrive to the program and pick up his/her sibling(s)______________________________ without me or an authorized picker upper present. He/she is responsible for leaving the program site with his/her sibling (s) independently at dismissal.我授权我的 GO 中学的孩子在没有我的情况下自己到达学校及接他/她的弟弟或妹妹______________________________。他/她将对自己接弟弟或妹妹放学负责。Student Independent Travel Agreement学生自己旅游同意书As a responsible GO Middle student, I hold myself accountable to the following:作为一个负责人的 GO 中学生，我同意：

1) I will report directly to/from home to GO Project Programming 我将直接向 GO 报告自己出发到学校或到家情况。

2) I will arrive on time and sign myself out with my teacher at dismissal.我将准时到达，并在解散时找老师签名离场。

3) I understand that GO staff will communicate any tardiness and/or absences with my parent/guardian daily. 我明白 GO 员工将与我父母/监护人联系如果我有任何缺勤。

4) I will not engage in any unsafe behavior during my travels to/from GO Project. 我不会参与任何不安全的活动。

____________________________________________ _________________________Parent/Guardian Signature 家长/监护人签名 Date 日期____________________________________________ _________________________Student Signature 学生签名 Date 日期

ACADEMIC RELEASE FORM学术信息发布声明表

The GO Project provides academic assistance to elementary school students who are below grade level. This form gives the GO Project permission to have access to any relevant academic information that will help us create individualized academic plan for your child in our comprehensive year-round programming. Once enrolled in the GO Project, this information can be accessed each year for the duration of the commitment to GO Project programming.

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In order for the GO Project to provide the best services for your children it is important for us to have access your child’s school records including information about enrollment, grades, test scores, OSIS numbers, Individualized Educational Plans, and attendance information. Additionally, we ask on a yearly basis that your child’s public school teacher complete a student evaluation form documenting their strengths and areas for development. Individualized Educational Plans, student evaluations, and report cards will be shared with your child's GO Project teacher.

I hereby give the GO Project my permission to access my child’s school records by the professional staff at the GO Project. This includes enrollment information, grades, test scores, OSIS numbers, Individualized Educational Plans, and attendance information, as well as a completed Student Evaluation Form and relevant academic information about my child for the duration of their participation at the GO Project.

GO Project 向成绩落后的小学生提供学术帮助。这份表格给予 GO Project 获取任意相关学术信息的许可，以帮助我们在全年项目中为您的孩子提供个性化教学方案。当您加入 GO Project，此类信息将在您孩子入学期间一直对我们开放。为 GO Project 能够更好地为您的孩子提供服务，我们有必要获取您孩子的学校记录，包括入学、年级、考试成绩、 OSIS 号、個別教育計劃 (IEP)，以及出勤记录。不仅如此，我们每年要求您孩子的公立学校老师完成一份学生评价表，记录他们的长项和需要提高的方面。Individualized Education Plan，学生评价，以及报告卡将与您孩子的 GO Project 老师共享。我在此给予 GO Project 许可，在孩子参与此项目期间，让 GO Project 的职业人士获取我孩子的学校记录。这包括入学信息、年级、考试成绩、OSIS 号、Individualized Education Plans 及出勤记录，以及完整的学生评价表和相关学术信息。Child’s name (学生姓名): _______________________________________________________________________

Parent/Guardian Name (家长、监护人姓名): _______________________________________________________

Parent’s Signature (家长签字): __________________________________________ Date (日期): ________________________________________________________________________________________________________________________________

PERMISSION TO PUBLISH PHOTOGRAPHS & OTHER INFORMATION

公布照片和其它信息的许可

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I hereby authorize the GO Project to take and use black and white, color, slide, and/or video photographs of my child or me for use in news media, newspaper, fundraising, and/ or additional materials for any purpose that the GO Project deems appropriate.

I understand and agree that I will receive no financial compensation for publication of any photos and information. I understand that this permission covers the entire time my child is enrolled in the GO Project.

我在此许可GO Project 拍摄并使用我孩子或我的黑白照片、彩色照片、幻灯片及影像资料，用于新闻媒体、慈善募捐及其它GO Project 认可的用途上。

我明白并同意我不会因任何照片或信息的公开而获得经济补偿。我明白这项许可在我孩子参与 GO Project 期间一直有效。Child’s name (学生姓名): _______________________________________________________________________

Parent/Guardian Name (家长、监护人姓名): _______________________________________________________

Parent’s Signature (家长签字): __________________________________________ Date (日期): ___________

Summer Field Trip Permission Slip 201 5 -201 6 2015-2016年度夏季出游许可

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My child (我的孩子)____________________________________(first and last name/名和姓) has my permission to attend the GO Project field trip during the GO Summer program (我的孩子在我的许可下可以参加 GO Project的 2015至 2016学年GO Summer出游项目).

During this trip my child will (在此期间我的孩子会)：

Be supervised by GO Project Staff, Interns, and Volunteers (接受GO Project职员、实习生和志愿者的管理) Travel by subway, both ways (来回乘坐地铁) Be expected to behave in a safe manner while traveling and visiting the theater (在旅游和访问剧院时注意安全) Wear his/her GO Project t-shirt (穿着他或她的GO Project体恤衫) Adhere to all GO Project rules and regulations (遵守 GO Project的全部规章制度)

In the event of an emergency, I can generally be reached at the following contact numbers (遇到紧急情况时，可以通过以下方式联系到我):

Home # (家庭电话)___________________ Cell # (手机)_____________________Work # (工作电话)___________________

If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf:

如果紧急情况下无法联系到我，我授权以下人员代表我1) Name( 姓名)_______________________________________________ Relationship (关系)_______________________________

Home # (家庭电话)______________________ Cell # (手机)_____________________Work # (工作电话)______________________

2) Name( 姓名)_______________________________________________ Relationship (关系)_______________________________

Home # (家庭电话)______________________ Cell # (手机)_____________________Work # (工作电话)______________________

Physician’s Name (医生姓名)___________________________ Phone Number (电话)________________________________

Physician License Number (医生执照号)_____________________

Physician’s Address (医生地址)____________________________________________________________________________

Family Medical / Hospital Insurance (家庭医疗、医院保险)_____________________________________________________

Insurance Company: (保险公司) ____________________________Policy # (条款)___________________________________

I give my permission for the adult in charge of the activity to take my son/daughter to a medical facility, if necessary. In case of emergency, if none of the above can be contacted, I consent to treatment for my son/daughter under the supervision of and as deemed necessary by a physician licensed under the Medical Practice Act. I agree to the release of any records necessary for treatment, billing or insurance purposes.

我准许活动负责人在必要时带我的儿子/女儿去医疗机构。在紧急情况下，如果无法联系到以上负责人，我同意我的儿子/女儿接受拥有Medical Practice Act执照的医生的治疗。我同意公开任何治疗、收费和保险所需信息。

______________________________ ______________________________ ________________

Parent/Guardian Name (家长/监护人姓名) Signature of Parent/Guardian (家长、监护人签) Date (日期)

GO Middle Summer Leadership Camp 2015Participation Information and Consent Form

(6th Grade/Rising 7th Grade Only)11

GO 中学暑假领导能力锻炼夏令营 2015 参与信息及同意书（仅限六年级毕业生/升七年级的学生）PLEASE NOTE: Each participant must provide the GO Project with the following information in order to

participate in the Leadership Camp in partnership with Ramapo for Children. Please write any limitation(s) and/or health related issues that we should be aware of in question #4请注意: 每次参与必须向 GO Project 提供以下信息以便参加夏令营。请在问题#4 写下任何限制或与健康有关的问题。

Student Information 学生信息:

Name姓名: _______________________________ Date Of Birth出生日期: _____________________

I _____________________________________, give permission for my child, _____________________

to participate in the overnight Leadership Camp in partnership with RAMAPO for Children from July 10 th

to July 12th. I understand that this is a mandatory camp for all rising 7 th graders attending the GO

Summer 2015 program. I also understand I must attend the GO Summer orientation and prepare

necessary materials for my child to attend this camp. I agree to drop-off and pick-up my child at Grace

Church School located on 86 Fourth Avenue, between 10th and 11th Streets.

我______________________同意我的孩子______________________参与三天两晚的从 7 月 10 日到7 月 12 日的领导能力锻炼夏令营。我明白这个夏令营对所有升入七年级的并参与 GO暑假的学生是强制性参加的。我也明白我必须参加 GO暑假介绍会并准备参加本夏令营的材料。 我同意接送我的孩子位于 86 Fourth Avenue, between 10th and 11th Streets 的 Grace Church School。

_____________________________________ _______________________

Parent/Guardian Signature 家长/监护人签名 Date 日期

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Address 家庭住址: ________________________________________________________________

Telephone#电话号码: __________________________________

Parent/Guardian Emergency Contact Information: 家长/监护人紧急联系：Name姓名: ________________________________________________________________________

Address住址: ___________________________________________________________

Home Telephone 家庭电话: ___________________ Work Telephone 工作电话: ______________

Cell Phone 手机: _______________________ Email邮件: ________________________________

Health/ Medical Information:

健康/药物信息1) Your Child’s Insurance Carrier 孩子保险公司: ___________________________________________

2) Policy Number政策号码: ________________________________________________

3) Does your child have any limiting, temporary or permanent injuries, illnesses conditions or disabilities that may interfere with his/her participation in a physically active, outdoor adventure program that may include warm-up games, initiatives, low and high ropes course activities, swimming, boating, and hiking?您的孩子有任何限制性的，暂时性的或者永久性的受伤，疾病或者残疾吗？以上请情况是否会影响他参加生理上的活动以及户外冒险活动包括热身游戏，跳绳活动，游泳，划船以及登山吗？

Yes（是） No（否） If yes, please identify and explain: 如果是，请详细说明

________________________________________________________________________________________________________________________________________________

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4) Please add any additional and pertinent information about your child, which may be helpful for

Program Staff: 请添加任何有关您孩子的额外的和相关的信息以便项目员工帮助您孩子。________________________________________________________________________________________________________________________________________________

The health information noted above is correct and I give consent for my child to engage in all camp activities except as noted on this form. 以上健康信息是正确的。我同意我的孩子参加所有夏令营里的活动除了这表格里提到的。Permission to Provide Necessary Emergency Care: I give my permission for the adults in charge of the activity to take my child to a medical facility, if necessary. In the event of an emergency, if none of the above can be contacted, I consent to treatment for my child under the supervision of and as deemed necessary by a physician licensed under the Medical Practice Act. I agree to the release of any records necessary for treatment, billing, or insurance purposes.必要紧急关照的同意书：我允许活动负责人在必要时带我的孩子去医疗设备。在紧急情况发生时，如果以上联系人无法被联系，我同意有医生执照的人员治疗我的孩子。我同意任何必要的有关治疗的费用或者保险。__________________________________ ___________________________Parent/Guardian Name 家长/监护人签名 Date 日期

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親愛的家長們 ，

請查看您收到的兩個表格，我們需要您的檢閱並簽署。如果您給予同意，這封信將會讓您了解我們所需問 及您的細節。

簽署 IRB的表格，將會允許我們直接從教育部得到您孩子的信息。這些信息是我們需要向您獲得的基本資 料（ ELA和數學成績，成績單等）。這個表格也將授權給我們可以採訪你的孩子，讓我們可以得到在您孩

子在參加 GO 項目的反饋，以便不斷提高我們的項目質量。

第二種表格是我們機構收到了來自紐約州的 Sandy 救濟金，這筆資金將用來提供支持額外的家長工作室，供應超市購物卡，並解決其他家庭在颶風 Sandy 之後的需要。

感謝您的支持與配合，我們將十分感謝您填寫兩張表格。如果你有任何問題，請不要猶豫可直接通過郵箱onunz@goprojectnyc.org或 347-377-2317 即可獲得解答。

謝謝,

Olivia NúñezDirector of Community Engagement

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亲爱的家长们和监护人们您们好， 为了更好地确保我们能够更好地给予您的孩子帮助，我们需要收集些关于您的孩子的 学术进步数据。 我们所有的调查过程都由一个独立的调查公司 Glass Frog Solutions 所监控。这些调 查员们将会使用这些信息去了解我们的服务以及如何去提倡学术。 我们被要求授权使用孩子的 OSIS号码。我们还将会与您的孩子简单谈谈他们在 GO Project 里的学习经历。您的孩子会被问到他们觉得 GO Project 的哪一部分很有趣以及他 们最喜欢的项目是什麽。这些对话将会被录音；录音将仅用于调查目的所用，之后将被摧毁。最后，我们还要上交一份简单的报告简述您的孩子是否觉得 GO Project有帮助。 我们重视您的孩子的隐私，所以正因为我们认为以上所需的信息有助于提高我们的教 学质量，我们才会在此请求并获取您的孩子的信息。我们保证我们将会严格保存您的孩子的个人资料，并且不会与第三方分享。我们向您保证我们仅将这些信息用于调查和达到项目目的。 签以下的同意书的同时，您并没有放弃任何法律权力，您仅是给予了 GO Project 和调 查人员们权限去获取您的孩子的学术记录和对话记录。所有信息将会严格保密。如果您改变了主意并决定不让我们获取您孩子的个人资料，您可以随时联系我们并撤销批准。您的参与对我们而言十分重要。这相比起孩子平时在学校遇到问题的风险更安全。 请填写完整第二页的同意书并和您的孩子一起交给我们。 如果您有任何问题，请联系我们的调查领导，Rebecca Casciano 博士 （rebecca＠glassfrog.us）。致上The GO Project 团队

The GO Project家长同意书

孩子的名字：_____________________________________

孩子出生日期：___________________________________ 我在此同意 The GO Project和 Glass Frog 获取我孩子的学校成绩记录以及简单的面 试和调查我的孩子。这些信息将会被保密并被用于评价 GO Project 的教学效果。我明白 我的孩子的任何个人信息将不会被利用做成报告。 在下面签名后，我同意我的孩子自愿参与这次评估并同意我已阅读和理解以上条 例。

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是的，我同意我的孩子参加 不，我拒绝我的孩子参加

__________________________________ __________________________________家长或监护人签名 日期

__________________________________书写家长或监护人的名字

我在此同意 Glass Frog 调查团队在我孩子的面试录音。这些信息将会被保密并被用于 评价 GO Project的教学效果。 在下面签名后，我同意我的孩子在面试中被录音。

是的，我同意我的孩子参加 不，我拒绝我的孩子参加

__________________________________ __________________________________家长或监护人签名 日期

__________________________________书写家长或监护人的名字

超强飓风桑迪补充社会服务津贴申请资格/服务同意书超强飓风桑迪补充社会服务津贴基金为受灾者提供无偿志愿服务。接受服务的人士必须为超强飓风桑迪的受灾者、居住在受桑迪影响的地区或受桑迪直接影响。根据联邦和州政府要求，下列细则保障有关人士的权益：

安全、周详及尊重个人自由的服务之权利。不受种族、肤色、性别、宗教、年龄、残疾、婚姻状况、国籍、族裔或性取向影响接受服务的权利。持续参与筹备、发展及定期修改服务計劃的权利。

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拒绝服务的权利。如资料会受公开，享有给予或拒绝书面签字同意书的权利。除法律要求或得到签署同意资料公开，享有隐私和记录保密的权利。阁下的记录有机会被州或联邦资助者检阅，以决定是否遵守合约义务。为保障儿童和家庭的最佳利益，须报告怀疑虐待或疏忽照顾儿童个案， 并可能在未得同意下作出报告。根据情况，包括从計劃退出，随时转介往其他服务提供者的权利。

我，____________________________________, 同意接受上述服务。我证明我达到下列其中一项资格要求; 1.)我是超强飓风桑迪的受灾者，2.)我居住在受超强飓风桑迪影响的社区，3.)我曾受超强飓风桑迪直接影响。計劃附加要求:

_____________________________________________ ____________________________

参加者签署 日期

_____________________________________________ ____________________________

計劃职员 日期

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