STUDENT DISCIPLINE LOG: 2010-2011 __________ NINE-WEEKS

NAME _______________________________________________ PERIOD _________

DATE OFFENSE STUDENT

ACKNOWLEDGEMENT

1. ________ ____________________________________________ _________

2. ________ ____________________________________________ _________

3. ________ ____________________________________________ _________

I AM AWARE THAT MY NEXT OFFENSE WILL RESULT IN THIS FOROM BEING SENT TO MY
PARENTS/GUARDIANS TO INFORM THEM OF MY MISCONDUCT AND TO FURTHER INFORM
THEM THAT MY NEXT OFFENSE WILL RESULT IN MY BEING REFERRED TO THE DEAN OF
STUDENTS FOR DISCIPLINARY ACTION. EACH OFFENSE THEREAFTER WILL RESULT IN A
REFERRAL TO THE DEAN.
________________________________________
Student signature

4. ________ ____________________________________________ _________

5. ________ ____________________________________________ _________

6. ________ ____________________________________________ _________

Dear Parent/Guardian,

Because my students are almost always good kids overall, I rarely have to send a student to the
Dean for any major infraction of my, the school’s, the county’s, or the state’s rules. A great deal
of my class time is spent, however, reprimanding students for silly infractions which, though not
serious in and of themselves, nevertheless are disruptive and counterproductive to the ability of
either your child/ward or his/her classmates to learn. For that reason, I have devised this form to
give my students ample warning that their conduct in class is unacceptable. If this form is being
sent home to you, it is only after your child/ward has received three warnings about improper
behavior. Please sign below to acknowledge that you have received this sheet and are aware that
your child/ward will be referred to the Dean of Students after another instance of breaking the
rules in class. Thank you for your time.

Teacher’s name
Department
GBHS

I have reviewed this form and discussed this matter with my child/ward.

__________________________________________________DATE_____________
PARENT/GUARDIAN SIGNATURE