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Date: ____________________________ Date: ____________________________

Item Confiscated: ___________________________ Item Confiscated: ___________________________


Teacher’s Name: ____________________________ Teacher’s Name: ____________________________
Subject: ___________________ Subject: ___________________
Signature: _________________________________ Signature: _________________________________
Name of Student: ___________________________ Name of Student: ___________________________
Grade and Sec.: _________________________ Grade and Sec.: _________________________
Signature: ________________________________ Signature: ________________________________
_______________________________________ _______________________________________
Date: ____________________________ Date: ____________________________
Item Confiscated: ___________________________ Item Confiscated: ___________________________
Teacher’s Name: ____________________________ Teacher’s Name: ____________________________
Subject: ___________________ Subject: ___________________
Signature: _________________________________ Signature: _________________________________
Name of Student: ___________________________ Name of Student: ___________________________
Grade and Sec.: _________________________ Grade and Sec.: _________________________
Signature: ________________________________ Signature: ________________________________
_______________________________________ _______________________________________
Date: ____________________________ Date: ____________________________
Item Confiscated: ___________________________ Item Confiscated: ___________________________
Teacher’s Name: ____________________________ Teacher’s Name: ____________________________
Subject: ___________________ Subject: ___________________
Signature: _________________________________ Signature: _________________________________
Name of Student: ___________________________ Name of Student: ___________________________
Grade and Sec.: _________________________ Grade and Sec.: _________________________
Signature: ________________________________ Signature: ________________________________
_______________________________________ _______________________________________
Date: ____________________________ Date: ____________________________
Item Confiscated: ___________________________ Item Confiscated: ___________________________
Teacher’s Name: ____________________________ Teacher’s Name: ____________________________
Subject: ___________________ Subject: ___________________
Signature: _________________________________ Signature: _________________________________
Name of Student: ___________________________ Name of Student: ___________________________
Grade and Sec.: _________________________ Grade and Sec.: _________________________
Signature: ________________________________ Signature: ________________________________
_______________________________________ _______________________________________

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