JJIAB -E1 (FORM )- PRIVATE SCHOOL STUDENTS - APPLICATION FOR PARTICIPATION IN CAPE ELIZABETH CO-CURRICULAR ACTIVITIES

The parent (or student if 18 years of age or older) must submit a separate application for each activity in which participation is desired.

STUDENT INFORMATION:

Student's Name:

Student's Date of Birth:

Grade in Private School:

Student's Address:

Phone Number:

Parent/Guardian's Name:

Private School Name:

Private School Address:

Private School Phone Number:

Private School Principal/Head's Name:

Student is applying for participation in the following activity: ___________________________

VERIFICATION OF ELIGIBILITY

I authorize__________________ (private school name) to provide the Cape Elizabeth School Department upon it request all information necessary to verify that my child, _____________________ (student's name) meets the eligibility requirements for participation in the co-curricular activity that is the subject of this application.

Parent Signature (or student, if 18 or older)_______________________ Date _____________

STUDENT PARTICIPATION AGREEMENT

I agree to comply with all Cape Elizabeth School Department policies, administrative procedures, and behavioral, disciplinary, attendance, and other rules that apply to the Cape Elizabeth students participating in the co-curricular activity that is the subject of this application.

Student Signature________________________________ Date_________________

Adopted:

• December 13, 2011