CONSEQUENCE NOTICE

Student: _____________________________ Teacher Referral: _______________________

Date:___________________
Type of Consequence:
Mediation/Detention ________________
Out-of-School _____________________
In-School ________________________
Reason for Consequence: ______________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Conditions: __________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Detention/Suspension will be served on: ___________________________________________________
Comments:

A.I.

______________________________________

__________________________

______________________________________

__________________________

______________________________________

__________________________

Administrator/Counselor __________________________ Student _____________________________

CC: Referring Teacher _____________________

File
Teacher Advisor
Parent
Counselor
Superintendent
School Board President
Only if suspension
Activities Director

Referral # ________ Difficulty _________