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Policy JJIAA-E4

JIIAA-E4 Verification of Private School Student Eligibility for Participation in SAD #4 Interscholastic Athletic Activities
NEPN/NSBA Code: JJIAA-E4 

VERIFICATION OF PRIVATE SCHOOL STUDENT ELIGIBILITY FOR PARTICIPATION IN SAD #4 INTERSCHOLASTIC ATHLETIC 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 INTERSCHOLASTIC ATHLETIC ACTIVITIES

_____ Written application received ____________ (DATE)

_____ Student’s written agreement to comply with behavioral, disciplinary, attendance, and other rules applicable to all students in SAD #4.

_____ Sports physical performed on ________ (DATE); Cleared to play? Yes / No

_____ Documentation of immunization presented

_____ Documentation of insurance

_____ Documentation of age eligibility

_____ Documentation of academic standing (principals may ask to see grades or other evidence that academic eligibility has been met)

_____ Student’s written agreement to abide by same transportation as regularly enrolled students

_____ Student has completed tryout

_____ Student has been selected /not selected for the activity (circle one)

Decision by: __________________________ (Name and Title) Date: ___________

Student/parent notified of decision: Date: ____________ Method: _____________

Adopted: January 10, 2012

M.S.A.D. #4
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