Student Discipline Form

I, __________________, behaved inappropriately in class on _______________. My

inappropriate behavior was:
_____________________________________________________________________________.
A better choice for me would have been:
_____________________________________________________________________________.
This would be a better choice because:
_____________________________________________________________________________.
If there is a next time, I will replace my bad behavior with a more appropriate action.
If my inappropriate behavior continues, I know the consequences will be:
1.
2.
3.
4.

Lunch Detention
Parent Phone Call
Parent Meeting
Sent to the Principal

If I make better choices, I know that the classroom will be a better place for all and I will do my
best to meet the classroom expectations.

I have read and agree with the discipline form above.

Student Signature: _____________________________________ Date: ___________________

Parent Signature: ______________________________________ Date: ___________________

Questions or Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________