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 ____________________________________