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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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