South Lyon Community Schools Disciplinary Referral Form

South Lyon Community Schools Disciplinary Referral Form

Student Name: / Date:
Click here to enter a date.
School: / Grade: / Administrator:
List of SchoolsCentennialBartlettBrummerDolsenHardyKent Lake MillenniumSalemSayre South Lyon HighSouth Lyon East / LevelK12345678910111212+ / List of AdministratorsM. AltermattA. BeutelL. Chudy-BowmanS. CooperK. DancerK. DoreeM. GoodemootC. HeitschK. GallagherR. MetcalfJ. MurphyD. PhillipsD. PlummerM. RosekransC. ScalingM. TeaganE. TestaniB. Toth
Location of Incident: / Time: / Referred by:
Classroom Room # Teacher
Hallway
Commons/ Cafeteria
Gymnasium
Off School Grounds
Bus
Outside the building (on school grounds)
Other (explanation) / PMAM
Parent/Guardian Contact
Parent/Guardian contacted by referring personnel at
AMPM via phonee-mailphone-left message.

This section is to be filled out by referring personnel.

Infraction Details (Explanation of the incident)
Interventions Attempted by Referring Personnel
This section is for office use only.
Action Taken By Administration (Explanation)
Parent/Guardian Contacted AMPM via PhoneE-mailMeeting Police Contacted N/AYesNo Board Policy Distributed
*(if applicable) Policy5530 Substance Abuse5516 Student Hazing5517.01 Bullying5772 Weapons
Discipline Categories Offense number for this category 1234567891010+
Category 1: Classroom/Staff
Not ApplicableVerbal abuse toward studentVerbal abuse toward staffInappropriate language or gesturesCheatingInappropriate or disruptive behaviorRefusal to identify selfPossession of food or beverageForgeryInsubordinationNuisance ItemsMisuse of SuppliesDisrespectful to Staff MembersLyingPantsingPlagiarismSleeping in classViolation of PED policy
Category 2: Dangerous Actions
Not ApplicableArsonDangerous BehaviorFightingAssaultPossession of a fire starterPossession of a firearmWeapon AwarenessPossession of a weapon other than a firearmThreats to studentsThreats to staffThrowing snowballsTampering with fire prevention device / Category 3: Substance Abuse
Not ApplicablePossession of AlcoholPossession of DrugsPossession of Drug ParaphernaliaDistribution of AlcoholDistribution of DrugsUnder the influence of Alcohol Tobacco use or PossessionUnder the influence of Drugs
Category 4: Student Related
Not ApplicableInappropriate behavior at a School ActivityHabitual OffenderExtortionDress Code ViolationGamblingBullying/ HarrassmentInciting a RiotOvert Display of AffectionSexual Harrassment VerbalSexual Harrassment Non-VerbalSexual Harrassment PhysicalViolation of School Acceptable Use PolicyTheftTrespassingPoor SportsmanshipParking Lot ViolationClosed Campus ViolationIndecent ExposureFailure to ParticipateRacial SlursRacial IntimidationPlayground ReferralBus MisconductSafe Schools Reporting / Category 5: Building Related
Not ApplicableLitteringDamage to EquipmentDamage to PropertyVandalism/GraffitiFood FightCafeteria/misconduct
Category 6: Attendance
Not ApplicableTruancyTardiesFailure to sign outFailure to serve detention- TeacherFailure to serve detention-Admin.
Office Use Checklist
Referral sent home, to attendance, and others (If applicable.)
Prior Suspensions (list dates and number of days)
Number of Cumulative Days Removed
MDR Scheduled (If applicable) Click here to enter a date. TBD
Procedural Safeguards distributed and documentation of this is in Skyward Click here to enter a date.
Consult with Case Manager held Click here to enter a date.
Change of Placement considered Noted in Skyward, Parent notified if establishedClick here to enter a date.
Pattern of behavior considered Noted in Skyward if established
Student Statement on file.
Homework Request made and noted in Skyward (If applicable)
Home-based instruction initiated and documented (If applicable)

Parent/Guardian Signature (If required)______Date______