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Date:________________________________________________________________

Student Name:________________________________________________________

Student Grade and Teacher:____________________________________________

Description of Violation:  ________________________________________________

____________________________________________________________________

____________________________________________________________________

Consequences Assigned:  (check all that apply)

______________  In-school conference with student and/or parent
______________  Required to change inappropriate attire/accessories
______________  Verbal contact with parent
______________  Loss of privileges (Describe)
______________  After-school Detention
______________  In-school suspension (Date)
______________  Out-of-school suspension (Date)

Comments:  _______________________________________________________________

_________________________________________________________________________

_________________________________________________________________________


_________________________________________________________________________

Administrator Signature and Date:  _____________________________________________

Student Signature and Date  __________________________________________________

Parent/Guardian Signature and Date____________________________________________

Cc:   Student File
Dress Code File