Pais/ Responsável Legal
Nome Completo e Apelido: (em seguida designado como “ os Pais/ Responsável”)
Endereço Físico:
Detalhes de Contato:
Criança: (em seguida designado como “a Criança”)
Nome Completo e Apelido:
Data de Nascimento:
Responsável da Viagem e Detalhes de Contato: (em seguida designado como “Responsável da Viagem”)
Nome Completo e Endereço:
1. Autorizo a criança a viajar com os Responsáveis da Viagem para o seguinte destino:
2. O período da viagem será a partir do______________________________.
3. Caso se revele impossível para notificar os pais / responsável de qualquer mudança nos planos de viagem devido a uma
situação de emergência ou imprevisto, autorizo o Responsável da Viagem para autorizar as mudanças de planos na viagem
desse tipo.
4. Caso o Responsável da Viagem em sua/ seu discrição exclusiva (que a discrição não deve ser indevidamente exercida)
considerou conveniente fazer planos de viagem especial para a Criança, voltou para casa devido a circunstâncias
imprevistas, aceito a total responsabilidade pelos custos adicionais que devem ser ocasionados por essa situação.
5. Eu indenizarei o Responsável de Viagem contra toda e qualquer reclamação que seja e qualquer ato decorrente, salvo se tais
afirmações surgem de negligência, negligência grave ou intenção deliberada durante o período especificado deste
Consentimento de Viagem.
6. Declaro que eu sou o responsável legal da criança e que eu tenho autoridade legal para conceder autorização de viagem ao
Responsável de Viagem da Criança.
7. A menos que é incompatível com o contexto, as palavras que significa no singular incluirá o plural e vice-versa.
Assinado em _________________________________________ no _______dia de __________ de 20____.
Assinatura _____________________________________________________________ (Pais/ Responsável)
Assinatura ____________________________ (Testemunha 1) Assinatura _________________________ (Testemunha 2)
*Assinaturas de testemunhas deve ser efetuadas por pessoas independents e não por alguêm indicado no formulário de consentimento de viagem.
Neste _____ dia de __________________ de 20____, antes de mim, a autoridade assinados, apareceu pessoalmente ___________________________________ provou-me através de prova satisfatória da identidade, a saber, __________________, ser a pessoa(s), cujo nome(s) é/são assinadas no documento anexo e que assinou na minha presença.
Assinatura do Oficial Notário: ________________________________________
Nome do Notário Digitado, Impresso ou Carimbado:
Vencimento da Comissão: _____________________________________
Oggolaanshaha Waalidka ee Booqashada Caalamiga
Parental Authorization for International Field Trip (Somali)
Tilmaamo:
Shaqaalah BPS: 1) Halkii booqasho hal foom isticmaal.
2) Buuxi qeybta foomka "School Portion" ee bogga 1.
3) Laba koobbi ka samee foomka halkii ardayba.
4) Hal koobbi u-dir guriga inay waalidka iyo ardaygu soo saxeexaan.
5) Xilliga booqashada, foomka orijinaalka ah ee saxeexan waa inuu sitaa hoggaamiyaha oo koobbina lagaga
tagaa xafiiska dugsiga.
Waalid/koriye sharci ah, haddii ardaygu ka yar yahay 18 sano, amase haddii uu ugu yaraan jiro 18 sano:
Guud-mar oo akhriso "Parental Authorization and Acknowledgement of Risks” ee bogga 2.
Buuxi qeybta “ appropriate information” ee bogga 2.
Buuxi qeybta "Medical Authorization" iyo “Medication Administration Form” ee bogga 3-5.
Ardayda: 1) Buuxi qeybta “Heshiis Arday” ee bogga 1.
WAXA BUUXIN DOONO DUGSIGA
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Magac Dugsi:
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Magac Arday:
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Taariikhda(aha) Booqashada:
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Goob:
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Ujeeddada:
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Liiska Hawlaha:
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Kormeerid: (Mid Calaamadee)
Ardayda waxa si toos ah booqashadan u-kormeeri doona waqti kasta hogaamiyayaal dad waaweyn ah.
Ardayda waxa si toos ah booqashadan u-kormeeri doona hogaamiyayaal dad waaweyn ah marka laga reebo
waxyaalahan:
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Qaab Gaadiid: (Calaamadi dhammaan kuwa khuseeya.)
□ socod □ baska iskuulka □ Tareenka MBTA □ Qaab kale _______________
Aradydu waxay ka bixi doonaan: ___________________________________ xilli _________________.
(halkee) (waqti)
Ardaydu waxay ku soo noqon doonaan: _____________________________ abbaaro_____________.
(halkee) (waqti)
Hogaamiyayaalka mas'uulka ah:___________________________________________________________________
Heerka Hagaamiye/Arday: __________________________ (ugu badnaan 10:1)
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WAXA BUUXIN DOONA ARDAYGA
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HESHIIS ARDAY
Markaan ka-qeybgalayo booqashadan, waxaan fahamsanahay inaan noqon doono wakiil BPS iyo komuyuunatigeyga. Waxaan fahamsanahay in qiyamka haboon la raaci doono, iyo inaan oggolaan doono mas'uuliyadda ku dhaqanka dabeecad wanaagsan oo aan raaco xeerarka dugsiga iyo Xeerka Anshaxa ee Dugsiyada Dadweynaha Boston (BPS).
________________________________ __________________
Saxeexa Ardayga Taariikh
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WAXA BUUXIN DOONA WAALIDKA/KORIYAHA AMASE ARDAYGA
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OGGOLAANSHO IYO AQOONSI KHATARO
Waxaan fahamsanahay in ka-qeybgalka booqashadani tahay mid mutadawacnimo ah oo aniga/ilmaheyga ii keeni kara khatar. Waxaan akhriyey oo fahmay faahfaahinta booqashada (ee bogga 1 ee foomkan) oo waxaan oggolaaday in aniga/imahaygu ka qeybgalo waxyaalaha la-qorsheeyey ee booqashada.
Waxaan anigu qaatay mas'uuliyadda khatar shakhsiyeed amasemid ku timaadda waxyeello hanti oo ka timaadada amase la-xiriirta ka-qeybgalka imahayga ee booqashadan oo ay ka mid yihiin ficillo daayacaad ah amase waxyaale kale laga bilaaby il-biriqsiga ilmahaygu hoos tago kormeerka BPS illaa inta ay booqashadu socoto. Waxaan kaloon oggolahay inaanan u-qabsan Dugsiyada Dadweynaha Boston (BPS) iyo qof kasta iyo urur kasta oo kale oo la-xiriira BPS xagga hawshan,oo ay ka mid yihiin balse aan ku xaddidneyn adeeg kale oo ay ka mid yihiin gaadiidka, inaan ku dacweeyo amase qaameeyo arrin la xiriirta ka-qeybgalka ilmahayga ee booqashadan.
Waxaan kaloo aan fahamsanahay in ka-qeybgalka booqashadu ay ku jiraan hawlo ka baxsan dhismaha dugsiga; sidaas darkeed, Dugsiyada Dadweynaha Boston iyo shaqaalaha iyo mutadawaciinta mas'uul kama ahaanayaan tayada iyo isticmaalka dhismaha aan ahayn kan dugsiga.
Waxaan fahamsanahay in BPS aanay mas'uul ka ahayn kormeerka aniga/ilmahayga xilliyada aniga/ilmagaygu ka maqan yahay hawsha la kormeerayo ee BPS. Xilliyadaas i waxay ku qoran yihiin qeybta "Kormeerka" ee bogga 1 ee heshiiskan.
Waxaan caddeynayaa in aniga/ilmahaygu akhriyey oo oggolaaday inay raacaan shuruudaha lagu sheegay Xeerka Anshaxa ee BPS, iyo inaan oggolaado dhammaan go'aannada ay sameeyaan macalimiinta, shaqaalaha, iyo kuwa awoodda leh. Waxaan oggolahay xaqa ay BPS u-leedahay inay fuliso xeerarka, qiyamyada, amarada. Waxaan oggolahay ka- qeybgalka aniga/ilmahayga ee booqashadan ay BPS joojin karto hadii aniga / ilmahaygu raaci waayo shuruudahaas, amase sabab kale oo ay BPS u-maleysay inay tahay danta kooxda ardayda ah, iyo in aniga/ilmahayga loo diri doono guriga aniga kharashka jeebkeyga oo aan lahayn soo-celin (refund). Intaas waxa dheer in hoggamiyayaashu ay beddeli karaan hawlaha si ay u-hubiyaan nabadgelyada qofka iyo/amase kooxda.
Waxaan aqbalay in aniga/ilmahaygu aanu qaadanay mas'uuliyad buuxda ee helidda iyo xifdinta dhammaan dhokumantiga looga baahan yahay ka-qeybgalka booqashadan dibadda ah, oo ay ka mid yihiin balse aan ku koobneyn baasaboor aan dhicin, fiisooyin, iyo aqoonsi sawir leh.
OGGOLAANSHO DAAWO
Waxaan caddeynayaa in aniga/ ilmahayga uu ku jiro xaalada jireed iyo mid maskaxeed oo fiican oo aniga/ilmahayga ma lihin xaalad gaara oo caafimaad amase jireed oo ka-hor-iman karta ka-qeybgalka booqashadan.
Waxaan oggolahay inaan dhammaan wada buuxiyo foomamka “Medical Information Form” iyo “Medication Administration Form” ee laga helayo bogga ugu dembeeya ee Oggolaanshahan.
Waxaan oggolahay inaan u-sheego BPS wixii daawooyin ah iyo/amase qoraallo daawooyin ay tahay in aniga/ilmahaygu qaato waqti kasta oo ka mid ah xilliga booqashada.
Haddii uu dhaco xannuun aad u xun amase dhaawac ilmahayga/korsadaheyga, waxaan oggolagay sida ku cad saxeexayga hoose in la siiyo kaalmo caafimaad oo degdeg ah, haddii ay sidaas ku taliyaan shaqaalaha caafimaadka ee fiirinaya ilmahayga. Waxa intaas dheer, inaan awood u-siinayo hoggaamiyaasha kor ku qoran inay wakiil ahaan aniga i-matalaan waalid/koriye ahaan xilliga uu ka-qeybgalayo booqashada kor lagu xusay taas oo ay ku jiraan gelinta iyo ka-saaridda ilmaheyga ee xarun caafimaad oo degdeg ah.
Haddii codsaduhu ugu yaraan jiro 18 sano, weerta soo socota waa inuu akhriyo oo uu saxeexo ardaygau:
Waxaan caddeynayaa inaan ugu yaraan jiro 18 sano, iyo inaan akhriyey oo aan fahmay Heshiiska kor ku qoran, oo aan oggolaaday oo la igula xisaabtimo doono qodobadan iyo shuruudahan.
_____________________
Saxeex Arday Taariikh
Haddi codsaduhu ka yar yahay 18 sano, weerta soo socota waa inuu akhriyo oo uu saxeexo ardayga waalidkiisa amase koriyihiisa sharciga ah:
Waxaan caddeynayaa inaan ahay waalid iyo koriye sharci ah, iyo inaan akhriyey oo aan fahmay Heshiiska kor ku qoran, oo aan oggolaaday oo la igula xisaabtimo doono qodobadan iyo shuruudahan aniga xaggeyga iyo anoo matalaya ardayga.
Waxaan fasaxayaa in: _______________________________________ uu ka-qeybgalo dhammaan hawlaha booqashada dibadda.
(Arday)
_____________________
Saxeex Waalid amase Koriye Taariikh
Ardaygu, haddii uu ugu yaraan jiro 18 sano, waalidka/koriyaha sharciga ah waa inuu buuxshaa macluumaadka hoos ku yaalla:
Daabac Magaca Koowaad iyo Kan Dembe: ___________________________________________________________
Cinwaan: ______________________________________________________________________________________
Teleefan: (Gacanta) ____________________ (Guri) _____________________ (Shaqo) _______________________
Magaca Koowaad iyo Kan Dembe ee Xiriirka "Emergency"ga: _____________________________________________
Waxa uu u-yahay Ardayga: ________________________________________________________________________
Taleefan Lambarada Xiriirka "Emergency"ga: __________________________________________________________
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Foomka Macluumaadka Caafimaadka- Medical Form (Somali)
Magac Arday: Taariikh Dhalasho:
Magaca(yo) Waalid/ Koriye:
Taleefan: (Gacanta)______________ (Guri) ___________________ (Shaqo)________
Taleefan: (Gacanta)______________ (Guri) ___________________ (Shaqo)________
Macluumaadka Qofka lala xiriiri karo xilliga degdega ah: (ee aan ahayn waalid/koriye)
(1) ________ _______
Magac Ehelnimada Ardayga
___________ ______ _______________________________
Taleefan Lambar Macluumaad kale ee qofka
(2) _____ _______
Magac Ehelnimada Ardayga
_________________ ______________________________ Taleefan Lambar Macluumaad kale ee qofka
Magaca Dhakhtarkiisa Koowaad iyo Macluumaadkiisa (haddii arrin degdeg ahi dhacdo):
Magaca Bixiyaha Caymiska Caafimaadka, Lambarka Xeerka, iyo Macluumaadka Xiriirka ealth (haddii arrin degdeg ahi dhacdo):
Macluumaad Amarada Doonashada Caymiska (haddii arrin degdeg ahi dhacdo):
Ardaygu wuxuu leeyahay arrimaha caafimaad ee soo socda iyo/ama alarji oo ay tahay inay oggaadaan Dugsiyada Dadweynaha Boston - BPS:
Arrimaha Caafimaad:
Alerjiyo (cunto, caafimaad, cayayaan, dhir, xayawaan, iwm.):
Ardaygu wuxuu qaataa dawooyinka soo socda iyo/ama qoraallo dhakhtar oo ay tahay inay oggaadaan Dugsiyada Dadweynaha Boston - BPS:
Liiska/isticmaalka daawooyinka:
Haddii dawooyinka la qaato marka loo baahdo, sheeg calaamadaha ama xaaladaha lagu qaadanayo daawada iyo waqtiga ay tahay in mar kale la siin karo.
Ma waxa jira xaalad ka dhigeysa in ilmahaagu qaato barnaamij xaddidan oo jimicsi ah? (sida asmada, qalliin cusub, xaalad wadne, acabsi aan caadi ahayn, iwm.)
Haddii ay tahay haa, sheeg siyaabaha aad u-rabtid in loo xaddido barnaamijka:
Macluumaad dheeraad ah oo la xiriira caafimaadka ardayga oo ay tahay inay oggaadaan Dugsiyada Dadweynaha Boston - BPS:
Waxaan amrayaa sii-deynta macluumaadka kor lagu bixiyey shaqaalaha dugsiyada kale si ay isu-duwaan adeegyada.
________________________________________________ ____________________
Saxeexa Ardayga, haddii uu jiro ugu yaraan 18 Taariikh
_________________________________________________ _________________
Saxeexa Waalid/Koriye, haddii uu jiro ugu yaraan 18 Taariikh
* Haddii loo baahdo, warqadda dhakhtarka ku dhaji foomkan.
* Haddii loo baahdo, nuqullada dhokomantiga tallaalka ku dhaji foomkan.
Foomka Daawo-siinta- Medical Administration Form (Somali)
*Fadlan socdaalkan ardaygaaga soo raaci daawooyinka muhimka ah oo qura.*
Magac Arday:
1. Magac Daawo _____________________________________________________________
Waqtiyaalka la qaadanayo ____________________________________________________
Sababta Daawada _________________________________________________________
Macluumaadka calaamadaha ay keento daawadu _________________________________
2. Magac Daawo ____________________________________________________________
Waqtiyaalka la qaadanayo ____________________________________________________
Sababta Daawada _________________________________________________________
Macluumaadka calaamadaha ay keento daawadu _________________________________
3. Magac Daawo ____________________________________________________________
Waqtiyaalka la qaadanayo ____________________________________________________
Sababta Daawada _________________________________________________________
Macluumaadka calaamadaha ay keento daawadu _________________________________
4. Magac Daawo ____________________________________________________________
Waqtiyaalka la qaadanayo ____________________________________________________
Sababta Daawada _________________________________________________________
Macluumaadka calaamadaha ay keento daawadu _________________________________
Macluumaad Dheeraad ah/Amarro Gaar ah:
Waxaan amrayaa in safarkan uu ilmahaygu qaato daawooyinka kor ku qoran.
________________________________________________ ____________________
Saxeexa ardayga, haddii uu jiro ugu yaraan 18 Taariikh
_________________________________________________ _________________
Saxeexa Waalid/Koriye, haddii uu jiro ugu yaraan 18 Taariikh
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