Code No. 102.2

School District

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, Name                                                            Grade Level               

Attendance Center                                                     

Approved:       February 26, 1996             

Reviewed:       January 16, 2006               

Revised:                                                     

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