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Policy JJIAA-R
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: _______________
The Following Documentation Will Be Required Prior To Administrative Approval For Participation:
Consent to release records
Evidence that the student currently meets the same behavioral, disciplinary, attendance, academic standing, and other eligibility applicable to all students in the South Portland School department;
Student’s written agreement to comply with the same behavioral, disciplinary, attendance, eligibility, and transportation rules applicable to all students in the South Portland School Department;
Documentation of sports physical (if applicable) and clearance to play; Documentation of immunization presented;
Birth certificate.
Consent To Release Records
I authorize ______________________ _____________ _______________ to provide to
Private School Name Phone Number Fax
____________________ upon its request all information necessary to verify that my
South Portland School
son/daughter, __________________________ meets the participation requirements in the
Student’s Name
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 South Portland School Department policies, administrative procedures, and behavioral, disciplinary, attendance and other rules that apply to South Portland students participating in the co-curricular activity that is the subject of this application.
I also agree to abide by the same transportation rules that apply to all South Portland participants in this activity.
________________________________________ ___________________________
Student’s Signature Date
Administrative Checklist
_____ Written application received ____________________
Date
_____ Student’s written agreement to comply with behavioral, disciplinary, attendance, transportation, and
other rules applicable to all students in South Portland
_____ Sports physical (if applicable) performed on ___________; Cleared to play? Yes/No Date
_____ 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 has completed tryout (if applicable)
_____ Student has been selected/not selected for the activity (circle one)
_____ Student participation in the desired activity is ______ approved ______not approved
Decision by: ______________ (Name and Title) Date: _____
Student/parent notified of decision: Date: ______ Method: ________
Athletic Director/Co-Curricular Advisor notified of the decision: Date:______ Method:________
*Please excuse any formatting errors.
