Professional Documents
Culture Documents
DREAM13 Foundation Value Students Initiative Form
DREAM13 Foundation Value Students Initiative Form
DREAM13 Foundation Value Students Initiative Form
This form is for any Marietta City Schools student from 2007-present. Please fill it out if you feel your
player has experienced any of the behaviors outlined in the questions. This form is 100% confidential.
None of your identity information will be shared with any school administrators or coaches. Your
personal identity is only visible to the DREAM13 officer gathering the data. We will only disclose who
you are if you grant us permission later if needed in the investigation process. There is zero fear of
disclosure or retaliation filling out this form. The purpose for the data gathering is so that everyone has
the ability to share their experience in a safe way and so that we can use that information to shape the
student’s environment and district policy moving forward. Thank you for participating. Your story will
change the future for our kids. You are not at fault for this happening and there is nothing to fear by
coming forward.
1. Has your child ever been the target of bullying, harassment, or intimidation as defined by Ohio
Revised Code which states, “any intentional written, verbal, electronic, or physical act which causes
mental or physical harm more than once.”? YES/NO
2. Has your child ever been the subject of abuse as defined by the CDC as, “any acts by any caregiver
such as a coach or teacher that results in physical or mental harm, potential harm, or threat of harm to a
child.”? YES/NO
Sport:__________________________
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3. Did you inform other coaches, Principal, Athletic Director, Superintendent, or Board Member of the
offending behavior? YES/NO
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6. Do you feel neglected or ignored by the administrators regarding the complaint you filed? YES/NO
7. Have you personally witnessed other players being subjected to abuse, bullying, intimidation, or
harassment by another coach as defined above? YES/NO
9. Please share anything else that you have personally witnessed by a coach that you feel is
inappropriate. ________________________________________________________________________
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10. Do you feel like the current administrators are concerned for your safety and well-being? YES/NO
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TODAY’S DATE
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PHONE _________________________
EMAIL _______________________________________________________________