POTTERVILLE MIDDLE SCHOOL

NO CONTACT CONTRACT

Student #1 Name __________________________________________ Grade _________

Student #2 Name __________________________________________ Grade _________

As of _______________ the students listed above have agreed to temporarily end contact or
communications with each other. This restriction includes:

• All comments or discussions with other student (verbal or written);

• Any gestures;

• Any comments or discussion with others regarding the situation or student;

• Any other actions that may be interpreted as provoking conflict between the students
who sign this agreement.

This contracted agreement is in effect until_______________. Any violation of this agreement will be
taken seriously and may result in further actions or consequences. This contract may be reviewed again with
a designated staff member after the contract expiration date or at the request of either student.

____________________________________ ____________________________________
Student #1 Signature Student #2 Signature

____________________________________ _____________
Signature of Staff Member Date