Parent / Guardian Name *

Name of parent /guardian contacting us or completing this form.

First Name

Last Name

Student Name *

List the primary child involved here. If any other children of your children are involved, identify them in the description box at the bottom of this form.

First Name

Last Name

Phone

(###)

###

####

Second Phone

(###)

###

####

Type of issue involved?

Check all that apply

My child has been accused of bullying / harassment

My child has been the victim of bullying / harassment

We have reported bullying / harassment to the school at least once (either orally or in writing)

Is your child in any of the following protected classes?

Please select all options that apply

Minority Race

Female

Disabled (504 or IEP)

Religion

Foreign Nationality

None of These

Not sure

Other (not listed)

If disabled above, is your child receiving any of these supports?

Service Plan (Private School)

504 Plan for Disability Accommodations

IEP (Individualized Education Plan)

None of These

A bullying / harassment investigation

Has started, but is not complete

Has not started, but one is expected

Has not started, and is not expected

Has been completed

Not sure

Discipline Related to the Bullying

Please select any that apply

My child is facing discipline or has been disciplined because of what happened

My child has not been disciplined

Other students may have been disciplined because of what happened

I'm not sure