Do not write in

this section.

Returned Forms: Class/Dept. Guidelines

Plagiarism Statement

STUDENT INFORMATION SHEET (please PRINT clearly)

Mr. York
(Check one) World Geography World History
Name:

Birthday:

Address:

Phone #:

City, State, ZIP Code:

I live with my:
Father/Guardian

Mother/Guardian

Name:
first

last

first

last

Workplace:
Work phone #:
Cell phone #:
E-mail address:

PERIOD

CLASS

CLASS SCHEDULE
ROOM #

TEACHER

1
2
3
4
5
6
7
8
Locker Number

Locker Combination

School attended last year

Teacher name

Extracurricular Activities (band, agriculture, volleyball, football, swimming, pep squad, debate, etc.):
Activity

Sponsor/Coach

Activity

DATE
Date:

Time:

Date:

Time:

Date:

Time:

Date:

Time:

Date:

Time:

CIRCUMSTANCE

Sponsor/Coach

NOTES

COMMUNICATION

COMMENTS

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

conference with student

email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

Date:

Time:

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

Contact Information
Student/Parent
Communication
DATE
CIRCUMSTANCE
NOTES
Date:

Time:

Date:

Time:

Date:

Time:

Date:

Time:

Date:

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________
accepted until __________ max grade ____
other:

Name _______________________________
COMMUNICATION

COMMENTS

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

conference with student

email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure

student conference
email
letter home
office referral

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

Time:

Date:

Time:

Date:

Time:

low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

phone call @ home

work
mother father
guardian
message no answer
other:

assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

absence notification
academics
dishonesty
failing/failure
low grade
missing assignment(s)
progress report
behavior/discipline
response to parent
contact
other

student conference
email
letter home
office referral
phone call @ home
work
mother father
guardian
message no answer
other:

discussed resolved continuing

conference requested _________________
grade penalty -N.C. -11 -22 -33
-50
assignment _________________________

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other:

accepted until __________ max grade ____

other: