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Request Restorative Conference for Virtual Diversion Placement Student(s) - High School
Use this form to submit a request when a student is placed on virtual diversion placement and requires a conflict resolution session prior to returning to school.
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* Indicates required question
Email
*
Your email
School Name
*
Choose
Beach High School
Groves High School
Islands High School
Jenkins High School
New Hampstead High School
Savannah Arts High School
Savannah Early College High School
Savannah High School
Sol C. Johnson High School
Windsor Forest High School
Woodville Tompkins High School
Name and title of person referring
*
Your answer
Phone number of person referring
*
Your answer
The SCCPSS email address for the Mediation Center to send the disposition and agreement
*
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Location of incident
*
Bus
Classroom
Hallway
Outside
Cafeteria
Other
Brief description of the problem or incident
*
Your answer
# of students involved
*
Your answer
Student #1 FIRST & LAST NAME
*
Your answer
Student #1 Date of Birth
*
MM
/
DD
/
YYYY
Student #1 Grade
*
9th
10th
11th
12th
Student #1 Gender
Male
Female
Transgender
Unknown
Clear selection
Student #1 Race
*
African American/Black
Asian
Caucasian/White
Hispanic / Latino
Multi-racial
Other
Unknown
Student #1 Does the student have a 504 or IEP?
*
Yes
No
Student #1 Parent/Guardian name & contact information (address, zip code, phone number, and email address)
*
Your answer
Student #1 Level of Offense
*
10-day virtual diversion placement
15-day virtual diversion placement
20-day virtual diversion placement
Student #1 Start Date of Virtual Diversion Placement
MM
/
DD
/
YYYY
Student #1 Anticipated Return Date
*
MM
/
DD
/
YYYY
Student #2 FIRST & LAST NAME (if applicable)
Your answer
Student #2 Date of Birth
MM
/
DD
/
YYYY
Student #2 Grade
9th
10th
11th
12th
Clear selection
Student #2 Gender
Male
Female
Transgender
Unknown
Clear selection
Student #2 Race
African American/Black
Asian
Caucasian/White
Hispanic / Latino
Multi-racial
Other
Unknown
Clear selection
Student #2 Does the student have a 504 or IEP?
*
Yes
No
Student #2: Parent/Guardian name & contact information (address, zip code, phone number, and email address)
Your answer
Student #2 Level of Offense
10-day virtual diversion placement
15-day virtual diversion placement
20-day virtual diversion placement
Clear selection
Student #2 Start Date of Virtual Diversion Placement
MM
/
DD
/
YYYY
Student #2 Anticipated Return Date
MM
/
DD
/
YYYY
If there are others you know of that should be part of the mediation, please list their name, role and contact details here:
*
Your answer
Have all parents/guardians been contacted and informed about the Virtual Diversion requirement?
*
Yes
No (if no, please email
cc@mediationsavannah.com
once all parties guardians have been informed)
If an administrator/teacher/other staff member is a party to the incident, please enter here their name, email, and contact phone number
*
Your answer
Who is the school representative that will attend the conference? Please provide name, email and contact number.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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