Activities Discipline Referral

Student Name: ________________________________________________ Date: _____________________

Coach/Teacher Name: ______________________________________________________________________

Reason for Referral:

Late 3 times (with no note) Talking back to coach/teacher

Refusing to follow direction Being disrespectful to team/cast

Did not return signed referral Other _________________________

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Number of previous referrals: ________________

Consequence of Behavior:

Extra exercise Verbal warning

Sit out of practice Sit out of game

(only after 2 or more referrals)

Contact Activities Director Meeting with parents

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Additional comments:

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Parent Signature Date