Leaders of Today Peace Academy 2021-22 Afterschool Application
Margaret Fuller Neighborhood House Peace Academy
MFNH SITE: 71 Cherry Street Cambridge, MA 02139 | (617) 547-4680
CAMBRIDGEPORT SITE: 89 Elm Street, Cambridge MA 02139
Contact: Megan Ryan, Program Manager | mryan@margaretfullerhouse.org 
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Email *
Looking for English? | ¿Buscas español?
English Version: https://forms.gle/8CBe6wsrnqvMxKZf7
Versión en español: https://forms.gle/jPKw5csDRap8odnG6

Dokiman Adisyonèl
-Kopi ID Paran
-Kopi nan Batistè Timoun nan oswa Paspò
-Prèv rezidans (kopi bòdwo sèvis piblik / kontra lwaye / lèt notary nan men mèt kay la)
-Verifikasyon Revni: 1 mwa nan paystubs ak / OSWA dokimantasyon tout lòt sous asistans finansye - Sipò Timoun, Sekirite Sosyal, Andikap, Lojman, elatriye.
-Dosye Vaksinasyon ak Dosye nan Fizik ki pi resan
-Fòm Pwogram Manje Swen pou Timoun ak Adilt (sa a pral kouriyèl apre aplikasyon an soumèt)

Sèten fanmi ka bezwen soumèt Dokiman espesifik:
Kondisyon Sante Kondisyon Elèv / Medikaman
-Fòm pou Swen Sante Endepandan pou chak kondisyon (doktè siyen an) - (sa a pral kouriyèl apre aplikasyon an soumèt)
-Fòmilè konsantman medikaman - (sa a pral kouriyèl apre aplikasyon an soumèt)
-Tout medikaman timoun lan egzije (preskri / vann san preskripsyon) nan anbalaj orijinal la - DWE GEN YON NAN premye jounen TIMOUN

-Dokiman sou Gadyen Timoun ki Mete ajou (ant paran yo, adopsyon / adoptif / chanjman nan gadyen legal)

Plan Edikasyon Endepandan pou Elèv (IEP) / plan 504:
-Kopi plan ki pi resan, plen IEP / 504
-Kopi dènye rapò sou pwogrè IEP a


Dokimantasyon ka soumèt nan imèl - mryan@margaretfullerhouse.org
Non paran / responsab la ranpli aplikasyon an | Name of Parent/Guardian filling out application *
Dat Jodi a | Today's Date *
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Enfòmasyon sou timoun lan | Child's Information
Non Timoun lan | Child's Name *
Adrès lakay | Home Address *
Dat NESANS| Date of BIRTH *
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Sèks | Sex *
Koulè zye yo | Eye color *
Koulè cheve | Hair color *
Wotè | Height *
Pwa | Weight *
Dat kòmansman timoun nan mande: | Child's requested start date: *
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Nan ki pwogram ou enskri pitit ou a? | Which program are you enrolling your child in? *
Orè timoun nan prevwa: Tanpri tcheke jou pitit ou a ap patisipe. | Child's projected schedule: Please check off the days your child will attend.
Lekòl la | School *
Kouran klas la | Current Grade *
Pwofesè  | Teacher *
Doktè / Klinik pou Timoun lan | Child's Physician/Clinic *
Nimewo telefòn doktè / klinik | Physician/Clinic Phone Number *
Doktè / Adrès Klinik | Physician/Clinic Address *
Asirans | Insur *
Nimewo politik | Policy number *
Dantis timoun lan | Child's Dentist *
Nimewo Telefòn Dantis la | Dentist's Phone Number *
Enkyetid espesyal oswa Limitasyon (eg egzanp restriksyon dyetetik; alèji; pwoblèm sante; ak bezwen emosyonèl oswa bezwen espesifik pou aprann.) Si pa gen anyen, tanpri ekri "okenn". | (Special Concerns or Limitations (e.g. dietary restrictions; allergies; health problems; and specific emotional or learning needs.) If none, please write "none.") *
Èske pitit ou gen yon IEP (Plan Edikasyon Endividyèl) oswa Plan 504? | Does your child have an IEP (Individual Education Plan) or 504 Plan? *
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