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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 ____________________________________