103.E1 Grievance Form for Complaints of Discrimination or Non-Compliance with Federal or State Regulations Requiring Non-Discrimination

I,_____________________________ , am filing this grievance because:
 
 
 
 
 
(Attach additional sheets if necessary)
Describe incident or occurrence as accurately as possible:
 
 
 
(Attach additional sheets if necessary)
 
 
Signature                   __________________________________________
 
Address                      __________________________________________
 
Phone Number            __________________________________________
 
If student, Grade Level        __________________________________________
 
If student, Attendance Center ____________________________________