JJIAA-E1 PRIVATE SCHOOL STUDENT APPLICATION FOR PARTICIPATION IN MSAD#11 CO-CURRICULAR ACTIVITIES

PRIVATE SCHOOL STUDENT APPLICATION FOR PARTICIPATION IN MSAD #11
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/Headmaster’s Name:

Student is Applying for Participation in the Following Activity: _______________________
________________________________________________________________________

VERIFICATION OF ELIGIBILITY

I authorize __________________________________________________________to provide to
Private School Name
MSAD #11 upon its request all information necessary to verify that my son/daughter,

_____________________________________________________ meets the eligibility Student's Name
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 MSAD #11 policies, administrative procedures, and behavioral, disciplinary, attendance and other rules that apply to MSAD #11 students participating in the co-curricular activity that is the subject of this application.

_______________________________________________ ______________
Student's Signature Date

Adopted: January 2012