STRATFORD HIGH SCHOOL
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REFERRAL
Instructor: Room: Department: Language Arts The bottom half of the Disciplinary Referral form is blank. Use this space to explain to the principal what has led to your receiving this referral. You may include information about previous steps you have taken to try to solve the problem (apology, action plan, teacher conference, etc.), why the problem hasn’t been solved, and even why you may disagree with the teacher’s decision to refer your case to the office. You may use the blank space below to make notes and draft your comments. You are advised not to write anything on the form in haste or anger, because what you say on the form will be considered by the principal who handles your referral. You probably want to make the situation better, not worse, so think of how your words can have a positive effect. Responsible, respectful language will show your teacher and the principal that you are serious about accepting responsibility for mistakes you may have made and ensuring you do not make them again. Pre-writing Notes and/or Rough Draft:
Developed by L. Addison Diehl, 2007. All rights reserved.
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