Vous êtes sur la page 1sur 1

September, 2010

Dear Parents/Guardians of A. P. Science Students and Science/Humanities Students,

You are being offered the opportunity to attend a series of free science lectures at the 92nd Street “Y”, titled “On the Brink -
Breakthroughs in Science” (and other lectures, as arranged, in addition the “On The Brink” lectures).

Your child is encouraged to apply for this lecture series which begins early in the Fall Term and continues through the
school year on various dates. Please see supplemental sheets for specifics.

To qualify to be selected as one of several students to attend your child must submit a brief letter of interest stating why
he/she should be selected, based upon his/her demonstrated interest and ability in Science, and his/her commitment to
attend all regularly scheduled lectures without exception and without excuse.

Student: Your application sheet, with your name, your prefect and the name of your A.P. Science Teacher/Science Teacher
is due to Mr. Zinn and Present Student Participants.

We look forward to hearing from you!

Mr. Eric Zinn


Program Coordinator, 92nd St. “Y” OTB Lecture Series
BTHS Science Department (Retired)
BTHS, Class Of 1963

*************************************************************************************************************
Student Name: ________________________________, ____________________________________
LAST NAME (Print) FIRST NAME (Print)

ID. #_______________ Prefect:_______________ Date(s) of Activity: Various throughout 2007 - 2008

Activity Destination: 92nd Street “Y” (92nd St. & Lexington Ave, NYC)
Home Telephone
#: (212) 415-5615 (Helen Conover, Director of Science Programs at the 92nd Street “Y”)
Purpose of Activity: “On The Brink – Breakthroughs In Science” & Other Misc. Lectures (As Arranged)
Address: 1395 Lexington Avenue, NY, NY 10128

PARENT CONSENT:
I, the parent/guardian of the student named above hereby give my permission for my child to take part in the activity described
above.

PARENT’S SIGNATURE: ______________________________________ Date: ___________

I agree not to hold Brooklyn Technical H.S. & any of its employees, The Department of Education & any of its employees
or its representatives, Mr. Zinn, any accompanying adult chaperone, The 92nd Street “Y” or any of its employees or sub-contactors
providing services to the 92nd Street “Y” responsible for any expenses or injuries that my child may incur while engaged in the trip.
I understand that my child is responsible for his/her behavior at all times and that my child may be sent home unaccompanied at
my expense if he/she misbehaves.
I understand that alcoholic beverages and/or illegal drugs are prohibited and have discussed this prohibition with my
child. I understand that if my child is found in possession of these substances, he/she will be subject to school disciplinary
procedures and possible criminal prosecution.
I understand that students who have violated the school’s discipline code may be excluded by the school from
participating in any future trips.
I agree that in the event of any injury or illness the teacher or chaperone in charge of the trip may act on my behalf in
obtaining medical treatment for my child. I have indicated on the back of this form any permanent or temporary medical or other
condition(s) including special dietary and medical needs, or the need for visual and auditory aids, which should be known about
my child.
I understand that my child can not participate in these trips without my express written permission to do so which I give
by signing this notification and consent form.

I understand that the following conditions apply:

A. My child is expected to travel to the 92nd St. “Y” UNACCOMPANIED directly from Brooklyn Technical H.S.
B. My child is expected to travel from the trip destination to my home UNACCOMPANIED

SIGNATURE OF PARENT/GUARDIAN: __________________________________ Date: __________