goprojectnyc.orggoprojectnyc.org/storage/Middle_Re-enrollment... · Web view我们所有的调查结果都由调查者监控着，这些调查人员来自一家独立的调查公司，叫做玻璃蛙（Glass

RETURNING: GO Project Student Re-Enrollment Form重返：GO Project 学生再入学申请表

GO Middle: Current 5th-7th Grade StudentsGO 中学：五至七年级

2018-2019

Important Dates 重要日期RE-ENROLLMENT APPLICATION DUE DATE: February 24, 2018

重新注册申请截止日期： 2018年 2月 24日

February 24, 20182018年 2月 24日

Student Re-Enrollment Form 2018-2019 is DUE.提交截止文件：学生重新入学申请表 2018-2019。

March 24, 20182018年 3月 24日

GO Project Student Evaluation Form, and Updated IEP (if applicable) are DUE.提交截止文件: 报告卡，GO学生评估表以及已更新的 IEP（如适用）。

June 2018 (TBA) 6月（待定）

Attend a Family Orientation. Program Fees DUE.参加家长迎接会。提交项目费用截止。July 2nd, 20182018年 7月 2日

First day of the summer session (8:45 AM-5:00 PM).暑期项目第一天（早上 8：45-下午 5：00）August 3rd, 20182018年 8月 3日

LAST DAY OF GO SUMMER (*Half-Day: Dismissal at 12:30pm)GO SUMMER最后一天（*半天：下午 12：30解散）

Required Documents需要的文件

The following documents must be submitted by the assigned deadline in order for your re-enrollment to be complete:为了保证重新入学申请的完整，以下文件必须于截止日提交：

• Completed Student Re-Enrollment Form (ALL sections must be filled out). (DUE: Feb 24, 2018)• 完整的学生重新入学申请表（所有选项必须填完）。(截止日期: 2018年 2月 24日)• Student Evaluation Form from your child’s classroom teacher. (DUE: March 24, 2018)• 您的孩子所在教室的老师填写的学生评估表。(截止日期: 2018年 3月 24日)• Copy of most recent report card and/or progress report. (DUE: March 24, 2018)• 最新的报告卡以及(或)进度报告的副本。(截止日期: 2018年 3月 24日)• Copy of Individual Education Plan (IEP) or Section 504 *if applicable. Only full IEP will be accepted.

(DUE: March 24, 2018) • 个人教育计划（IEP）的副本或第 504章*如适用。只接受完整的 IEP。(截止日期:年 3月 24日)• Copy of Promotion in Doubt (PID) letter from your child’s school*if applicable. (DUE: Mar. 24, 2018)• 您的孩子所在学校的留级警告信（PID）的副本*如适用。(截止日期: 2018年 3月 24日)

GO Project Returning Student Re-Enrollment Form: GO MIDDLE 1

Fees & Scholarships费用以及奖学金

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 GO Summer Family Orientation. 项目费用是一位学生$80。项目费用可通过支票（check）或汇票（money order）来支付，并且必须要在 GO Summer 家庭欢迎会期间提交。

• Scholarships are available for families who qualify. • 奖学金会提供给符合条件的家庭。• The Scholarship Application must be completed on page 7.• 奖学金申请表必须在第五页上完成。• Scholarship availability is based on the financial needs of our families and the scholarship funds

available to the GO Project. • 奖学金的提供是建立在家庭的经济需求以及 GO Project可提供范围下。


RETURNING: GO Project Student Re-Enrollment Form重返：GO Project 学生再入学申请表

GO Middle: Current 5th-7th Grade StudentsGO 中学：五至七年级

2018-2019

In order to complete your child’s re-enrollment application, please make sure to complete ALL sections of this document and submit this form with all required documents by the due date to:

为了保证您的孩子再入学申请的顺利完成，请确保填写该文件所有的部分并且将词表以及所有要求的文件于截止日期前提交至：

The GO Project Main Office at 50 Cooper Square, 3rd Floor, New York, NY 10003.

SECTION ONE: General Applicant Information

第一部分：申请人基本信息

Child’s First Name (孩子的名字，除去姓氏): _________________________________________________

Last Name（姓氏）: ______________________________________________________________________

Date of Birth (mm/dd/yyyy)（出生年月日(月/日/年)）: _______/_______/____________

Gender（性别）: Male（男） Female（女）

Present Grade （所在年级）:______________ Public School（公立学校）: ________________________

Student School Identification Number (OSIS Number) (学生学校证明号（OSIS号）): _________________

T-shirt Size （T恤尺码）: XS S M L XL XXL OTHER（其他）: ___

SECTION TWO: Contact Information and Authorized Pickup


第二部分: 联系方式以及授权接孩子的监护人

Home Address（家庭住址）: ______________________________________ APT（房间号）: __________

City（城市）: _______________ State（州）: ______ Zip Code（邮编）: __________

Mailing Address (if different)（邮寄地址（若不同于家庭住址）:

____________________________________________________________________________

____________________________________________________________________________

Home Phone (家庭电话): ___________________________________________________________________

On the phone, I prefer to speak (在电话里，我希望讲):

English （英文） Mandarin （普通话） Cantonese （广东话）

Other（其他）:_________ _

It is best to contact me during the following time periods (Check all that apply)（我希望在以下时间段取

得联系）:

早上 8：00-中午 12：00 中午 12:00-下午 4：00 下午 4：00-下午 8：00

SECTION TWO CONTINUED: 第二部分（续）：PARENT/GUARDIAN ONE（家长/监护人一）:


Parent/Guardian’s Full Name（家长/监护人姓名）: ____________________________________________

Relationship to Child（与孩子的关系）: ______________________________________________________

Please check if the statement applies（请选择符合的选项）:

Living with child（和孩子住在一起） Financially supporting child (给孩子提供经济资助)

Is this person an emergency contact? (此人是否为紧急联系人?) Yes(是) No(否)

Mobile（手机号码）: _______________________ Work（工作电话号码）: _______________________

Email Address（邮箱地址）: _______________________________________________________________

Currently employed?（现是否工作？） Yes（是） No（否） Monthly salary（月薪）: $_______


English（英文） Mandarin（普通话） Cantonese（广东话） Other（其他）:_____

PARENT/GUARDIAN TWO家长/监护人二:

Parent/Guardian’s Full Name（家长/监护人姓名）: ____________________________________________

Relationship to Child（与孩子的关系）: ______________________________________________________

Please check if the statement applies（请选择符合的选项）:

Living with child（和孩子住在一起） Financially supporting child (给孩子提供经济资助)

Is this person an emergency contact? (此人是否为紧急联系人?) Yes(是) No(否)

Mobile（手机号码）: _______________________ Work（工作电话号码）: _______________________

Email Address（邮箱地址）: _______________________________________________________________

SECTION TWO CONTINUED: 第二部分（续）

Currently employed?（现是否工作？） Yes（是） No（否）Monthly salary（月薪）: $________



English（英文） Mandarin（普通话） Cantonese（广东话） Other（其他）:_____

AUTHORIZATION PICK-UP/EMERGENCY CONTACTS（授权的接孩子/紧急联系人）:

Please list three other emergency contacts (over the age of 16) that are not listed on the previous page, that 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)_______________________________________________________________________________________ Full Name(姓名) Relationship to Child(与孩子的关系) Phone（电话号码）



GO MIDDLE INDEPENDENT ARRIVAL/DISMISSAL:

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。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。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) 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)

SECTION THREE: Household Information 第三部分：家庭信息

Is your child currently in foster care? （您的孩子现在是在寄养吗？) Yes（是） No（否)


Household Size (家庭人数): Single Parent/Guardian Household (单亲家庭)

Two-Parent /Guardian Household (双亲家庭)

Number of people in household (including you & your child) 家庭人数（包括您和您的孩子）: ________

Annual Household income (required, documentation may be requested):

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)

SECTION FOUR: Scholarship Application第四部分：奖学金申请您在支付项目费用时遇到经济上的困难了吗？如果是，您可以申请 60美元的全额经济资助奖学金。这会将本年度的年项目费用由 80美元减免至 20美元。

Are you interested in applying for the $60 GO Project Scholarship?（您有兴趣申请 60美元的 GO Project 奖学金吗？） Yes（是） No（否)

If you choose to apply, please briefly explain your request to support your response.

如果您选择申请，请简要解释您的请求，以支持您的回复

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

SECTION FIVE: Medical Information第五部分：医疗信息

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)

您的孩子是否曾被诊断有多动/注意力缺少症 ADHD/ADD，焦虑，抑郁或其他行为或认知失调症？

Yes（是） No（否) **如果回答“是”，请继续回答以下问题:

** 医生的诊断结果是什么症？(If yes, what is the diagnosis):_________________________

** 医生是否有开药？(Was medication prescribed?) Yes（是） No（否) **如果回答“是”，请列出药名专注达 Concerta _____ 毫克mg 阿得拉 Adderall ____ 毫克mg 利他林 Ritalin ____ 毫克mg 其他 Other: ________________ _____ 毫克mg

Asthma（哮喘）

**If yes: （如果是）: Severe Persistent （严重持续） Moderate Persistent（中度持续）

Mild Persistent（轻度持续 Intermittent（间歇性的）

**If yes, is the child prescribed asthma medication? （如果是，孩子是否有哮喘的药物治疗？）

Yes （是） No（否)

**If yes, please list all medication(s)（如果是，请列出所有的药物？） Albuterol（舒喘宁）

Ventolin（喘乐) Flovent（氟替卡松） Singulair（顺尔宁）

Other:（其他） ________________________________________________________

SECTION FIVE CONTINUED: 第五部分续

Allergy (过敏)

** If yes, please list and describe the allergy specifications below:（如果是，请在下表中列出和描


述过敏的详细说明)

Allergen过敏原 Reaction/Symptoms反应/症状

Treatment/Medication/Dosage治疗/药物/剂量

Food allergy: (i.e. peanuts, shellfish, etc.)

食物过敏：（例如，花生、贝类，等）

Epi Pen required （需要 Epi Pen）

Environmental allergy: (i.e. pollen, dander, etc.)

环境过敏：（例如，花粉、皮屑，等）


Medication allergy: (i.e. Penicillin, etc.)

药物过敏：（例如，青霉素，等）


Other medical condition（其他医疗条件）: ____________________________________________

SECTION FIVE CONTINUED: 第五部分续

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): __________________________________________


Does your child take any medications other than those listed above? （除了以上列出的之外，您的孩子

是否还需要服用其他药物？） Yes（是） No（否)

** If yes, please specify the type of medication your child takes（如果是，请详细说明您孩子所需

服用药物的种类）________________________________________________________________________

Do any of the medications listed above require administration during the GO Summer program hours (8:45 AM - 5:00 PM)? 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？

Yes （是） No（否)

**Please Note: GO Project is unable to administer medication during the GO School Saturday program (9:30 AM - 12:30 PM). 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。

CHILD’S DOCTOR INFORMATION: 儿童医生信息:

Doctor’s Full Name (医生姓名): ___________________ Doctor’s Telephone (医生电话): ______________

Doctor’s Address (医生地址): ______________________________ Doctor’s Fax (医生传真): ____________

SECTION SIX: Academic Information第六部分：学术信息CLASSROOM INFORMATION:课堂信息

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): _______________________________________

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) did your child repeat? 如是，哪一级，哪一年: _________

My child is currently Promotion in Doubt (PID) for the current school year:我的孩子现在有 2018至 2019 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

SPECIAL EDUCATION SERVICES (IF APPLICABLE):特殊教育服务（如果适用）

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: IEP（是：IEP各别教育计划） Yes: Section 504（是：第 504节） No: My child does not receive special education services.（否：我的孩子没有收到特殊教育服务）

**If yes, please submit a 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 applicable, my child receives the following special education services:

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): _____________________

SECTION SIX CONTINUED: 第六部分续

ENGLISH AS A SECOND LANGUAGE:英语作为第二语言

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, my child’s current ESL Level is (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

OTHER:其他

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 Winter（冬季） Spring （春季） Multiple （多种 ) None（没

有）Has your child been suspended this year?（您的孩子今年是否被暂停？） Yes (是)

No (否)

**If yes, when?（如果是，什么时候？） ______________________________________________


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GO Project父母同意书亲爱的家长或监护人，我们开展的这个项目是为了确保我们提供给您孩子的服务可以使他/她的未来变得更好。作为这个过程的一部分，我们希望可以收集一些数据资料，以确保我们可以追踪您孩子的学术进程。我们所有的调查结果都由调查者监控着，这些调查人员来自一家独立的调查公司，叫做玻璃蛙（Glass Frog Solution）。调查人员将会使用这些信息来了解更多我们的项目，以及提高学习质量。我们需要您孩子的社会安全卡号码（OSIS number）来存取他/她的学术以及学校记录。这些记录包括纽约州数学和英语成绩，年级课程，以及出勤率记录。另外，我们还需要记录一些基本的个人信息，比如您孩子的性别和GO Project Returning Student Re-Enrollment Form: GO MIDDLE 13

年龄。当你在这份同意书的时候，并不代表您放弃任何的合法权利。你是简单地给 GO Project 和调查人员同意声明，表示我们可以记录您孩子的学术和学校记录。我们尊重和珍惜您孩子的隐私，我们是为了提高您孩子在这个课程的学习质量才向您要取这些信息。我们向您保证我们会严格保护您孩子的个人信息，绝对不会分享给任何不属于 GO Project 和调查组的人。我们确信我们运用这些信息只是为了调查和课程目的。另外，如果您改变主意，决定不再希望我们存取您孩子在学校的记录，您可以在任何时候与我们联系，并撤销。您的参与是完全自愿的。在参与这个课程中，除了一些您的孩子可能在学校经常遇到的风险之外，参加这个课程是绝对安全的。请您填好在第二页的同意书，并让孩子拿回来给我们。如果您有任何关于我们将如何使用您孩子的信息这方面的问题，请联系我们的领导调查者，Rebecca Casciano 博士。（[email protected]）GO Project 团队敬上


mailto:[email protected]

GO Project父母同意书孩子的姓名：___________________________________________

孩子的出生日期：_________________________________

孩子的学校身份证号码(OSIS No.): _______________________

我同意 GO Project 和 Glass Frog 调查公司存取我孩子的学术记录。（纽约州数学和英语成绩，年级课程，以及出勤率记录）以及一些基本的个人信息，例如性别和年龄。所有的信息都将会被保存妥当，并被运用来分析这个课程对我孩子学术需求的影响和帮助。我明白不会有任何的报告来透露我孩子的身份，包括名字，性别，人种，或者其它个人特征。当我在下面的横线上签名的时候，我同意 GO Project 用我孩子的记录来对课程进行分析。同时，我保证我已经阅读以及明白我孩子的信息将如何被运用。

__________________________________ __________________________________家长签名/合法监护人签名日期__________________________________打印的家长/合法监护人签名

ACADEMIC RELEASE FORM

GO Project Returning Student Re-Enrollment Form: GO MIDDLE

我同意，我孩子的记录可以被用于课程分析不同意，我拒绝我孩子的记录被用于课程分析

15

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.

In order for the GO Project to provide the best services for your children it is important for us to have access to 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/Guardian’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

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/Guardian’s Signature (家长签字): __________________________________________________________

Date (日期): _________________________________________________________________________________



Field Trip Permission Slip 2018-2019 2018-2019年度夏季出游许可


My child (我的孩子)____________________________________(first and last name/名和姓) has my permission to attend GO Project field trips (我的孩子在我的许可下可以参加GO Project的 2018至 2018学年GO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 Student Independent Arrival/ Dismissal Authorization Form

GO 中学生独自到校或离校授权表 GO Project Returning Student Re-Enrollment Form: GO MIDDLE 21

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

Parent Name 家长姓名: __________________________

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:作为一个负责任的 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



GO Project 医疗表格 / GO Project Medical Form (Page 1/2)

截止日期: 2018年 3月 24日GO Project Returning Student Re-Enrollment Form: GO MIDDLE 23

To be filled out by your child’s doctor/physician and returned to GO Project:由您孩子的医生填写并交回给 GO Project

By mail at 50 Cooper Square, 3rd Floor, New York, NY 10003 or by fax at 646-837-6042.

邮寄地址：50 Cooper Square, 3rd Floor, New York, NY 10003 或传真：646-837-6042

Child’s First Name:（孩子的名）__________________ Child’s Last Name:（孩子的姓）_______________

Routine Medication: 日常服药Please list ALL medications that this child currently and routinely takes (including, prescription, non-prescription, or over-the-counter). 请列出孩子目前日常服用的所有药物（包括：处方、非处方，或成药）

This child does not take medications on a routine basis.这个孩子没有日常服药 This child does take medications on a routing basis. 这个孩子日常服药

Medication Name药物名称 Dosage剂量 Frequency频率 Diagnosis/Comments诊断/注释

Other Authorized Medications: 其他授权药物As this child’s healthcare provider, I authorize that (unless otherwise noted in “Remarks”) the medications listed below can be dispensed at the discretion of medical personnel at GO Project.

“ ”作为这个孩子的医疗保健提供者，我授权（除非备注中另有说明）下面列出的药物可以由 GO Project的医务人员自行决定

Drug Name药物名称 Indications适应症 Remarks备注Acetaminophen (Tylenol) Pain or fever 疼痛或发烧Ibuprofen (Advil) Pain or fever 疼痛或发烧Diphenhydramine (Benadryl) Allergic reactions (insect bites, hives)过敏反应（昆虫

叮咬，荨麻疹）Antihistamine (Claritin) Nasal congestion/ Seasonal Allergy Symptoms 鼻充

血/季节性过敏症状Antibiotic Ointment Superficial cuts/ abrasions表面切伤/擦伤Hydrocortisone Cream Allergic reactions (contact dermatitis, insect bites)

过敏反应（接触性皮炎，昆虫叮咬）Children’s Antacid (Mylanta) Upset stomach 胃部不适

GO Project 医疗表格 / GO Project Medical Form (Page 2/2)

Doctor’s Signature (REQUIRED):


医生签名（必填）I certify that the medical history of this child is correct, and that he or she has medical clearance to engage in all activities, except for those noted on this form. In addition I authorize that (unless otherwise noted in “Remarks” above) medications listed under Other Authorized Medications section can be dispensed at the discretion of medical personnel at GO Project.

我证明这个孩子的病史是正确的，他或她有参与所有活动的医疗许可，除了在此表格上注明的那些。此外，我授权“ ”（除非上述备注另有说明）其他授权药物部分所列出的药物可以由 GO Project的医务人员自行决定

Doctor’s Name (Print): 医生姓名（打印体）________________________________________________________________

Date: 日期 ___________________________________________________________________________________________

Doctor’s Signature: 医生签名 ____________________________________________________________________________

Parent/Guardian Signature: 家长/监护人签名_______________________________________________________________
