JB-F: Complaint of Discrimination

Name of Complainant: _________________________________________________________________________

Studentís School and Class: ____________________________________________________________________

Address, Email Address, and Phone Number(s):

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Parent/Legal Guardian Name, Address, Email addresses, and Phone Number(s):

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Date(s) of Alleged Discrimination: ________________________________________________________________

Name of person(s) you believe discriminated against you or others:

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Please describe in detail the incident(s) of alleged discrimination, including where and when the incident(s) occurred. Please name any witnesses that may have information regarding the alleged discrimination. Attach additional pages if necessary.

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Please describe any past incidents that may be related to this complaint.

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I certify that the information provided in this report is true, correct and complete to the best of my knowledge.

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Signature of ComplainantDate
Complaint Received By:_____________________________________________________
 Compliance OfficerDate

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