SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

IN-SCHOOL SUSPENSION ASSIGNMENTS

Student ______________________________ Teacher _______________________________

Date _________________________________ Course _______________________________

Student assigned for _____ days. Beginning ______________ Ending _________________

Date Given _________ Date Completed __________ Date Returned to Teacher ___________

Assignments Returned Daily Yes_____ No______

Please attach any special instructions or supplemental assignments.

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

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