Book: I
Section: Instruction
Title: Verification of Private School Student Eligibility for Participation in Portland Public Schools Extra Curricular Activities
Code: IHBGC-E4
Status: Active
Adopted: February 3, 2015
VERIFICATION OF PRIVATE SCHOOL STUDENT ELIGIBILITY
FOR PARTICIPATION IN PORTLAND PUBLIC SCHOOLS 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 Portland Public Schools
_____ Sports physical (if applicable) 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: ______________________________________ Date: _______________
(Name and Title)
Student/parent notified of decision:
Date: ________________ Method: _________________________
IHBGC-E4 Verif of Priv Sch Std Eligibility for Part in PPS Extra-Curr Activities.pdf (9 KB)
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