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What to do:

1.
2.
3.

Get a Time-out Assignment sheet.


Think about why you are here.
Complete the Time-out Assignment
sheet.
4.
Turn the sheet into the teacher.
5.
Teacher will put the sheet in your
planner to be signed by your parent or
guardian.

Name: __________________________________________
Date: __________________
___________________

Time:

What rule did I break?


____________________________________________________
____________________________________________________
____________________________________________________
What can I do to improve my behavior?
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Student signature:
__________________________________
Teachers comments:
____________________________________________________

____________________________________________________
____________________________________________________
Parent signature:
____________________________________

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