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 ____________________________________