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South Lyon Community Schools Disciplinary Referral FormStudent Name:Date: FORMTEXT ?????Click here to enter a date.School: Grade: Administrator: FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Location of Incident: Time:Referred by: FORMCHECKBOX Classroom Room # FORMTEXT ????? Teacher FORMTEXT ????? FORMCHECKBOX Hallway FORMCHECKBOX Commons/ Cafeteria FORMCHECKBOX Gymnasium FORMCHECKBOX Off School Grounds FORMCHECKBOX Bus FORMCHECKBOX Outside the building (on school grounds) FORMCHECKBOX Other (explanation) FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ?????Parent/Guardian ContactParent/Guardian contacted by referring personnel at FORMTEXT ? FORMDROPDOWN via FORMDROPDOWN .This section is to be filled out by referring personnel.Infraction Details (Explanation of the incident) FORMTEXT ?????Interventions Attempted by Referring Personnel FORMTEXT ?????This section is for office use only.Action Taken By Administration (Explanation) FORMTEXT ????? FORMCHECKBOX Parent/Guardian Contacted FORMTEXT ????? FORMDROPDOWN via FORMDROPDOWN FORMCHECKBOX Police Contacted FORMDROPDOWN FORMCHECKBOX Board Policy Distributed *(if applicable) FORMDROPDOWN Discipline Categories Offense number for this category FORMDROPDOWN Category 1: Classroom/Staff FORMDROPDOWN Category 2: Dangerous Actions FORMDROPDOWN Category 3: Substance Abuse FORMDROPDOWN Category 4: Student Related FORMDROPDOWN Category 5: Building Related FORMDROPDOWN Category 6: Attendance FORMDROPDOWN Office Use Checklist FORMCHECKBOX Referral sent home, to attendance, and others (If applicable.) FORMCHECKBOX Prior Suspensions (list dates and number of days) FORMTEXT ????? FORMCHECKBOX Number of Cumulative Days Removed FORMTEXT ????? FORMCHECKBOX MDR Scheduled (If applicable) Click here to enter a date. FORMCHECKBOX TBD FORMCHECKBOX Procedural Safeguards distributed and documentation of this is in Skyward Click here to enter a date. FORMCHECKBOX Consult with Case Manager held Click here to enter a date. FORMCHECKBOX Change of Placement considered FORMCHECKBOX Noted in Skyward, Parent notified if establishedClick here to enter a date. FORMCHECKBOX Pattern of behavior considered FORMCHECKBOX Noted in Skyward if established FORMCHECKBOX Student Statement on file. FORMCHECKBOX Homework Request made and noted in Skyward (If applicable) FORMCHECKBOX Home-based instruction initiated and documented (If applicable) Parent/Guardian Signature (If required)________________________________________ Date____________________ ................
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