SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

DISCIPLINE REFERRAL

STUDENT NAME

SEX

GRADE

TEACHER

***NOTICE TO PARENT***

This is to inform you of a disciplinary incident involving your child.

Explanation of student offenses Date ________________ Time _________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Teacher Signature__________________________________

Recent Action Taken by Teacher Prior to this Notice
______ ______ ______ ______	Teacher conference with student Name in disciplinary notebook Conference with team Other____________________	______ ______ ______ ______	Parent conference Parent phone call Letter to parents Time out

Action Taken by Administration

___Conference with student…………………… Date:______________

___Conference with parents………………..….. Date:______________

___Phone call to parents……………………….. Date:______________

___Detention……………………………………. Date:______________

___Suspension……………………….………….. Date______________

___Expulsion Hearing Pending

___Other___________________________________________________

Action Taken By:_____________________Student Signature:_______________________

Notes:

Date:_____________________

Time:_____________________

III. 37