JJIAB-E4 (FORM)- VERIFICATION OF PRIVATE SCHOOL STUDENTS - ELIGIBILITY FOR PARTICIPATION IN CAPE ELIZABETH EXTRACURRICULAR ACTIVITIES

A separate application must be received for each activity in which participation is desired. This form is used to verify eligibility and to approve/deny participation.

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:

FOR EXTRACURRICULAR ACTIVITIES

Written application received ______________ (Date)

Student's written agreement to comply with behavioral, disciplinary, attendance and other rules applicable to all students in Cape Elizabeth Schools received ______________ (Date)

Student’s written agreement to abide by same transportation as regularly enrolled students _____________ (Date)

Sports physical (if applicable) performed on _________________ (Date)

Cleared to play ______ yes ______ no

Tryout (if applicable) ______ yes ______ no

Selected (if applicable) ______ yes ______ no

Documentation:

Immunization ______ yes ______ no

Insurance ______ yes ______ no

Age eligibility ______ yes ______ no

Academic standing (principal may ask to see grades or other evidence that academic

eligibility has been met) ______ yes ______ no

Student participation in the desired activity is ______ approved ______ not approved.

Decision by_______________________________________________________ (Name & Title)

Student/parent notified of decision: _______________ (Date) _______________ (Method)

Adopted:

• December 13, 2011