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NCA Student Concern Form (for Parents/Students)
Please complete this form when you have a concern related to a student's social emotional, mental health or safety.
*If the concern is immediate
, please contact an administrator.
*If this is an emergency call 9-1-1.
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* Indicates required question
Student Name
*
Your answer
Student Grade
*
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Unknown
Your name
Note: Your name will
NOT
be shared with the student you are reporting. This information is only shared in case we need more information.
*
Your answer
What is the nature of the concern?
*
Verbal Statement
Written Statement
Social Media Post
Student Behavior
Other:
Please describe the concern in detail.
*
Your answer
When did you become aware of the concern?
*
Your answer
An administrative team member needs to meet with this student
*
today
tomorrow
next week
no meeting necessary
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