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 Discipline Imposed or Pending *

Please select all options that apply

Detention

In-School Suspension

Out-of-School Suspension

Expulsion (including recommendations for expulsion)

Emergency Removal

There is a Pending Investigation

Other (not listed)

Is Your Child on Any of the Following Supports? *

Service Plan (Private School)

504 Plan for Disability Accommodations

IEP (Individualized Education Plan)

None of These