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 _____________________________________________

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