Student Reflection Sheet

Student Name: ______________________________

Report to room: ____________________________ Time Sent: ______________
Time arrived at withdrawal room: _____________ Time returned: ___________
Withdrawal Teachers Signature:

Student to complete: (These answers form a part of your agreement to re-enter class,
so do this right the first time or you will have to do it again).

How many times have you been withdrawn from class this week? _______
1. What happened?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. What did the teacher try to stop this from getting worse?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Who has been affected by what you have done? How?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4. What do you need to do to make things right?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5. Now complete the work you have been given.

RE-ENTRY AGREEMENT – CONDITIONS

1._______________________________________________________________________
2._______________________________________________________________________
3._______________________________________________________________________
Student Signature: ______________________

Teacher Signature: ______________________