CENTRES DE LA JEUNESSE

ET DE LA FAMILLE BATSHAW
YOUTH AND FAMILY BATSHAW CENTRES

Les Centres jeunesse

de Montral
Institut universitaire dans le domaine
de la violence chez les jeunes

FICHE DE SIGNALEMENT DE
NON-FRQUENTATION SCOLAIRE
A. Identification de llve
Nom: _____________________________________

Prnom: ___________________________

Date de naissance: _____/_____/_____

an
ms
jr
Adresse:

______________________________

Tlphone:

__________________________

______________________________

Code postal: __________________________

______________________________
Pre

Mre

Nom:

______________________________

Nom: _____________________________

Prnom:

_______________________________

Prnom:

_____________________________

Adresse:

_______________________________

Adresse:

_____________________________

_______________________________
Tlphone: _______________________________

____________________________
Tlphone: ____________________________

Garde lgale: ________________________________________

Nom de lcole: _____________________________________________________________________________
Type dcole:

Ordinaire___

Spciale___

Type de classe:

Ordinaire___

Spciale___

Prcisez: __________________________________________________________________________________
Placement lextrieur de la famille: (nom, adresse, no. de tlphone)
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B. Description de la situation familiale

1. Que connaissez-vous de la situation de llve dans sa famille?
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2. Que connaissez-vous de la capacit des parents fournir lencadrement ncessaire llve pour quil frquente lcole?
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C. Description du problme de non-frquentation scolaire

1. Depuis quand llve sabsente-t-il de lcole et quelle frquence?
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2. Quelles sont les raisons invoques par llve et les parents pour justifier les absences?
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3. Llve a-t-il des problmes de comportement lcole? Si oui, quels sont-ils?
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4. Quelles sont les dmarches effectues par lcole pour remdier la situation? (appels tlphoniques, lettre aux parents,
services de support par un travailleur social ou un ducateur, rencontre avec les parents, llve, la direction, etc...)
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5. Llve et ses parents reoivent-ils des services lextrieur de lcole? Si oui, lesquels?
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6. Quels sont les rsultats obtenus par les services offerts lcole et lextrieur de lcole?
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7. Que savez-vous des activits de llve en dehors de lcole depuis quil ne frquente plus?
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8. Commentaires ou inquitudes?
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IDENTIFICATION DU DCLARANT

Date du signalement :

_______
an

_______
mois

_______
jour

Nom de lenfant : ________________________________________________

Date de naissance : ______________________________________________

SIGNALANT
Nom : _________________________________________________________
Prnom : ______________________________________________________
Fonction : _____________________________________________________
Nom de lcole : ________________________________________________
Adresse de lcole : _____________________________________________
Tlphone de lcole : (________)________________________

Direction de la protection de la jeunesse ( DPJ)

Rception et traitement du signalement
1001 boul. de Maisonneuve est, 6e tage
Montral, (Qc)
H2L 4R5
Tl: 896-3100
Fax: 896-3190

Direction de la protection de la jeunesse /

Youth Protection Division
4515, Sainte-Catherine ouest
Westmount (Qc)
H3Z 1R9
Tl: 935-6196
Fax: 939-0597

De faon gnrale, les clientles francophones et allophones doivent tre signales la Direction de la protection de la jeunesse des Centres jeunesse de Montral. Les clientles anglophones et juives doivent tre signales la Direction de la protection de la jeunesse des Centres de la jeunesse et de la famille Batshaw.