Parent/Student Form for Reporting Possible Bullying/Inappropriate Behavior

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Bullying Definition: Any severe or pervasive physical or verbal act or conduct, including communications made in writing or by means of an electronic act by a student, or a group of students, directed against another student with the intent to ridicule, harass, humiliate, or intimidate the other student while on school grounds, traveling to or from school, or at a school-sponsored activity which substantially disrupts the educational evnironment.

Reports will be investigated no later than the end of the next school day and report of outcome to parent within 30 days. The school is not permitted to provide information about other students or discipline issued to other students with the reporting parent.

Name of student (target): *

Date of Birth

YYYY

School: *

Matthew Gage MS

Other

Grade: *

Other

Teacher/Counselor

Parent Name

Telephone/Cell *

Email address:

Full Name and grade of Offending Person(s) *

Give details of your concerns including dates/times, location(s), witnesses, etc. Please provide specific examples of the offensive conduct. *

What remedy are you seeking?

Describe the informal efforts that you have made to correct the situation you described:

Anonymity: *

Please DO NOT use my name/my child's name while investigating. Indicate reason below.

It is ok to use my name/my child's name while investigating.

Reason to NOT use child's name:

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