JJIAA-E1 Private School Student Application for Participation in SAD #4 Co-Curriculuar Activities
NEPN/NSBA Code: JJIAA-E1 

PRIVATE SCHOOL STUDENT APPLICATION FOR PARTICIPATION IN SAD #4 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 to SAD #4 upon its request, all information necessary to verify that my son/daughter, ___________________ (student’s name) meets the eligibility requirements for participation in the co-curricular activity that is the subject of this application.

_________________________________________         _______________________
Parent’s Signature (or Student’s, if 18 or older)                 Date

STUDENT PARTICIPATION AGREEMENT

I agree to comply with all SAD #4 policies, administrative procedures, and behavioral, disciplinary, attendance, and other rules that apply to SAD #4 students participating in the co-curricular activity that is the subject of this application.
__________________________________________         ______________________
Student’s Signature                                                             Date

Adopted:     January 10, 2012

M.S.A.D. #4