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“Home of the Steele-Heads”
Cell: (336) 989-1203
http://www.futureacademyinc.bravehost.com
coachkdfa@yahoo.com
Student Name: ____________________________ Grade: _____ School: _________________
Teacher: _________________________________ Principal: ___________________________
Date of Incident: _________ Parent/Guardian: ____________________ Phone: ___________
Why was the student expelled or suspended?
Physical Assault on an Adult
Written Assault on an Adult
Possession of a Firearm
Possession of Other Types of Weapons
or Instruments
Possession of a Firearm Look-Alike
Communicating Terrorist Hoax
Inciting Student Disorder
Trespassing
Attendance
Cheating
Sexually Inappropriate Behavior
Use of Tobacco Products
Non-compliance with Directives
Bus Misbehavior
Verbal Abuse/Disrespectful
Gambling
Forging Notes/Documents
Open Lunch Compliance
Arson/Possess Explosive Devices
Unjustified Activation of Alarm
Fighting among Students
Extortion
Theft/Destruction
Robbery/Burglary/Violence
Aggressive Physical Actions
Disruption of School
Illegal Substance/Alcohol or
Drug Paraphernalia
Skipping (Truancy School)
Skipping (Leaving once present)
Unexcused Tardies
Additional Information: __________________________________________________________
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______________________________________________________________________________
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Action Taken: __________________________________________________________________
______________________________________________________________________________
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Principal/Assistant Principal’s Signature: __________________________ Date: _____________
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