EXHIBIT
STUDENT DISCIPLINE
REFERRAL OF STUDENT TO PRINCIPAL
_________________ ________________ ____________ _____________
Student's Name Date/Time Sent Teacher Period/Room
Purpose for which the student is being referred _______________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
If the referral is for misconduct, have you previously referred this student for the same, or similar, reason(s)? ◻ Yes ◻ No
Do you desire to confer with the principal, or the principal's designee, before disciplinary action is taken? ◻ Yes ◻ No
Is it your intent to file a Notice to Principal of Refusal to Readmit Student?
◻ Yes ◻ No ◻ Possibly
REMINDER: All documentation substantiating the reason(s) and condition(s) for a refusal to readmit the student following the student's temporary removal pursuant to A.R.S. 15-841 must be provided by the next business day following the temporary removal.
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Teacher's Signature