the study of things Essay example

Submitted By lucamg
Words: 661
Pages: 3

Supplemental Internship Fund – Parental Consent & Placement Information
All information should be typed, except signatures. All fields must be complete; form must be printed, signed, in ink, by parent or guardian (see pg. 2), and scanned and emailed to the WBLRC at WBLBOX@schools.nyc.gov. (The Consent to Photograph is optional)

Student Information

First Name:

Middle Initial:

Last Name:

School:
LaGuardia High School

Grade:

Graduation Date:

CTE Field of Study:
TECHNICAL THEATRE

OSIS #:

Gender

E-mail:

Social Security #

Date of Birth:

Payroll cannot be finalized without a working e-mail – please check often!

Home Phone:

Cell Phone:

Address (please include floor or apartment #)

Number & Street:

Apartment #:

Borough:

State:

ZIP Code:

Internship Parameters
Total Number of Internship Hours Budgeted (REQUIRED)
140

Start Date:
10/20/2014

End Date:
1/25/2015
Projected Hours/Week:
10
School Providing Credit (yes/no):
YES
Notes:
RELATED INSTRUCTION PROVIDED

Internship Provider Information
Company Name:
LaGuardia High School – SCENERY
Worksite Address:
100 Amsterdam Avenue
Borough:
Manhattan

State:
NY
ZIP Code:
10023
Industry / Sector:
Public Sector

Supervisor
First Name:
John

Last Name:
Marean
Phone:
212-496-0700

Extension:
1901
Fax:
212-724-5748

email: jmarean@schools.nyc.gov Job Description and Information
Job Title:
Technical Theater Scenery Intern
Job Description:
Provide supervision and support for the operation of the Scene Shop. Act as a Scenic Carpenter, Assistant Shop Supervisor, or other position as designated by the Scenery Shop Supervisor.
Work as a carpenter, rigger, or other required position.

Supplemental Internship Fund – Parental Consent & Placement Information (continued)

Student
First Name:

Middle Initial:

Last Name:

Parent or Guardian

First Name:

Last Name:

Relationship to Student:

Parent Phone:

Emergency Contact (If different from Parent or Guardian listed above)

First Name:

Last Name:

Relationship to Student:

Phone:

Mobile:

Email:

OPTIONAL – Consent to Photograph, Film, or Videotape a Student for Non-Profit Use
(e.g. educational, public service, or health awareness purposes)
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the Student named above by the Work-based Learning Resource Center (WBLRC). I also grant to the WBLRC the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

SIGN HERE - OPTIONAL

Signature of Student

Date

SIGN HERE - OPTIONAL

Signature of Parent/Guardian (required if student is under 18)

Date…