Intermediate School 230 a

73-l 0 34 Avenue
Jackson Heights, New York 11372
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Sharon Terry, Principal Telephone : (71 8) 335 -7 648
Fax : (718) 335-7513
Bibi Rahamatulla, Assistant Principal
Ron Zirin, Assistant Principal
lzett Thomas, Assistant Principal Enrique Salazar, Parent
Coordinator Donna Vitale,
Assistant Principal

Camera Gontract

Student Name: C lass:

Canon Powershot and 2 GB SD card Seri al #:

Condition received: (to be filled out upon your inspection)

NEW GOOD DAMAGED (please list)

o The above camera is property of LS. 230.

o This camera is assigned to you for this school year only. It must be surrendered to Ms. Ramirez or
Ms. Beemsigne upon request.
o The purpose of the camera is to facilitate a better understanding of digital photography.
o Do not use the camera in any manner that goes against existing school rules.
o Do not take inappropriate pictures with this camera.
o Once you have signed for this camera it becomes your responsibility.
o Inspect the camera upon receiving it. The camera will be inspected damages when returned.
The camera should be returned in the same condition as when you obtained it. If there is a
malfunction notifu Ms. Ramirez immediately.
o If the camera is lost, stolen, or damaged you must notifu Ms. Ramirez or Ms. Beemsigne
immediately. You will be responsible for the replacement cost the camera which is $ 120.00.
o If the guidelines stated above are not followed the camera will be confiscated immediately.

By signing this form I acknowledge that I understand and agree to the terms and conditions stated above..
I understand I will have to reimbursement the school if I damage or lose this camera.

Student Name (PRINT): Student Signature

Parent/Guardian Name Parent/Guard ian S ignature

Home Address:

Home Phone #

Parentl Guardian Cell Phone # Parent I Guardian Work Phone #