Upper Township School District Disciplinary Referral Form
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1UPPER TOWNSHIP SCHOOL DISTRICT
DISCIPLINARY REFERRAL FORM
NOTICE TO PARENT(S)/GUARDIAN(S)
The purpose of this report is to inform you of a disciplinary incident involving your child. If you need
to speak to someone regarding this incident, please contact the school’s Main Office.
STUDENT’S NAME _______________________________ GRADE ______ CLASS ____________
DATE OF INCIDENT _________________________ TIME OF INCIDENT ____________________
LOCATION OF INCIDENT ___________________ REPORTED BY _________________________
DESCRIPTION OF INCIDENT ________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
THIS SECTION MUST BE FILLED OUT PRIOR TO SENDING REFERRAL TO THE OFFICE
ACTION TAKEN (Check as many as apply)
__ No Previous Action Taken
__ Separated Student from Group
__ Changed Student’s Seat
__ Held Conference with Student
__ Sent Previous Report Home
__ Warning
__ Attempted to Contact Parent: Left Message Date(s)/Time(s)________________________________
__ Parent Contact: (name) ___________________ Date(s) /Time(s)____________________
__ Held Conference with Parent: (name) ________________ Date(s)/Time(s)____________________
__ Other (explain) ___________________________________________________________________
PRESENT ACTION TAKEN: (This Section for Administrative Use Only)
st
nd
rd
th
th
INFRACTION: ______________________________ NUMBER OF OFFENSE(S): 1
2
3
4
5
__ Administrative Warning
__ Time in Office
__ Guidance Referral
__ Lunch Detention
__ Parent Contact
__ Restitution
__ Detention
__ Parent Conference
__ CST Referral
__ In School Suspension
__ Loss of Privileges
__ Peer Mediation
__ Out of School Suspension
__ Bus Suspension
__ I&RS Referral
Detention:
Date(s)/Time(s)______________________________
Number of Days_________
Suspension:
Date(s)_____________________________________
Number of Days ________
COMMENTS: ______________________________________________________________________
__________________________________________________________________________________
Student’s Signature ______________________________________
Date __________________
Administrator’s Signature _________________________________
Date __________________
Parent’s Signature _______________________________________
Date __________________
CC: Parent, Teacher, Student Discipline File
Date Entered on PowerSchool: _______________
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