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									Hendricks Public School District #402
            200 E Lincoln
        Hendricks, MN 56136
           507-275-3115
     http://hendrickspublicschools.org
 shelly.jensen@hendrickspublicschools.org

      Bruce Houck, Superintendent
        Shelly Jensen, Principal
                 1
We, at Hendricks Public School District, work hard to focus on delivering a quality
education for your student. To be successful in today’s world, students need to be
able to function in an appropriate manner behaviorally and socially. Parents and
teachers need to work together to guide students in making appropriate choices,
develop character traits, and achieve academically.

Our school district mission is “Hendricks Public School…where learning empowers
students to become creative thinkers, problem solvers, and life-long learners, well
versed in basic skills as well as life skills, effective citizens and productive caring
members of society.” We strive to provide your child with the opportunity to grow and
to develop for success in today’s world and offer instructional programs to assist
each child in his or her learning needs.

With our tradition of excellence, the vision of our school is to provide a strong skill
based curricular system that empowers students with the use of technology that
meets the individual needs of the students along with a family centered
environment.

The school board has approved the policies and procedures cited in this handbook.
District policy numbers are listed in the appropriate sections of this handbook.
Copies of the full policy governing each section are available at the district office.

As parents, you are urged to visit school often. You are invited to meet with the
teachers of your child (ren). A phone call in advance will assist in finding the proper
time for a meeting or just come in and visit the school to see it as it functions during
a regular day.

If a problem arises, come and see us. Difficulties can best be resolved when parents
and staff work together.




                                            2
                                           Dear Parents,
                                             Welcome to Hendricks Public School. We
                                             have developed this student handbook for you
                                             and your child to use as a guide for our
                                             school’s expectations. Please keep this
                                             handbook to refer to throughout the year.

                                           Let me be the first to welcome our Middle
                                           School and High School back to Hendricks!
                                           Our staff is very excited to begin this new
                                           adventure with you and your child. With all
                                           the changes that our students will experience
                                           this year, our staff is ready and willing to
                                           provide the needed assistance to make your
child feel at home away from home. Please come and visit us anytime. The students love
to share their day with you.

If you have any questions, please feel free to contact me at 507-275-3115. My email address
is shelly.jensen@hendrickspublicschools.org and our website is
http://hendrickspublicschools.org.

Sincerely,
Shelly Jensen
Principal




                                               “Alone we can do
                                            so little; together we
                                              can do so much.”
                                                           ~Helen Keller




           If you can dream it, you can do it.
                     ~Walt Disney




                                             3
                        Hendricks Public School
                             Phone: 507-275-3115

                               Fax: 507-275-3150

                     Office Hours: 7:30 am – 4:00 pm




                                 School Hours
                           School Begins – 7:50 am
                           Tardy Bell – 8:00 am
                           Dismissal – 3:15 pm
           Please do not send your child to school before 7:30 a.m.


                                 Early Dismissals
                       1:00 P.M. dismissals on the following
October 19th               November 23rd              February 17th      April 4th
               Children will be provided lunch before being dismissed.




  Believe you can and you're halfway there.
             ~Theodore Roosevelt



                                         4
                                 Hendricks Public School District Calendar
                                                2011-2012
           July 2011                                                     January 2012
  S   M     T   W    T      F    S                                 S    M     T    W    T    F    S
                            1    2                                 1    2     3    4    5    6    7 2 – No School
 3    4    5     6    7     8    9                                 8    9     10   11   12   13   14 3 – School Resumes
 10   11   12   13   14     15   16                                15   16    17   18   19   20   21 16- Staff Development
 17   18   19   20   21     22   23                                22   23    24   25   26   27   28
 24   25   26   27   28     29   30                                29   30    31
 31

          August 2011                                                   February 2012
  S   M    T    W    T      F    S                                 S    M     T    W    T    F    S
      1    2     3    4     5    6                                                 1    2    3    4
 7    8    9    10   11     12   13 17 - Staff Development         5    6     7    8    9    10   11
 14   15   16   17   18     19   20 18 - Staff Development         12   13    14   15   16   17   18 17-Early Out
 21   22   23   24   25     26   27 22 - First Day of School       19   20    21   22   23   24   25 20-Presidents Day – No School
 28   29   30   31                                                 26   27    28   29                    Comp Day



      September 2011                                                         March 2012
  S   M     T   W    T      F    S                                 S    M     T    W    T    F    S
                      1     2    3 2 – Vacation – No School                             1    2    3
 4    5    6     7    8     9    10 5-Labor Day – No School        4    5     6    7    8    9    10 9 – End of 3rd Quarter
 11   12   13   14   15     16   17                                11   12    13   14   15   16   17     47 Student Days
 18   19   20   21   22     23   24                                18   19    20   21   22   23   24 12- Staff Development
 25   26   27   28   29     30                                     25   26    27   28   29   30   31



       October 2011                                                          April 2012
  S   M     T   W    T      F    S                                 S    M     T    W    T    F    S
                                 1                                 1    2     3    4    5    6    7 4 – District Early Out
 2    3    4     5    6     7    8 19 – End of 1st Quarter         8    9     10   11   12   13   14 5 & 6 -Spring Break – No School
 9    10   11   12   13     14   15      41 Student Days           15   16    17   18   19   20   21 9 -Easter Monday – No School
 16   17   18   19   20     21   22 19- Joint Early Out,           22   23    24   25   26   27   28    Comp Day
 23   24   25   26   27     28   29 20 & 21 – EM – No School       29   30
 30   31

      November 2011                                                          May 2012
  S   M    T    W    T      F    S                                 S    M     T     W   T   F     S
           1     2    3     4    5                                            1     2   3   4     5 15-Last Day of School
 6    7    8     9   10     11   12                                6    7     8     9  10 11      12 15-End of 4th Quarter
 13   14   15   16   17     18   19 23 – District Early Out        13   14    15   *16 *17 *18    19    43 Student Days
 20   21   22   23   24     25   26 24-25 Thanksgiving             20   21    22   23 24 25       26 16-Staff Development
 27   28   29   30                                                 27   28    29   30 31               19-Graduation



      December 2011                                                          June 2012
  S   M     T   W    T      F    S                                 S    M     T    W    T    F    S
                      1     2    3                                                           1    2
 4    5    6     7    8     9    10                                3    4     5    6    7    8    9
 11   12   13   14   15     16   17                                10   11    12   13   14   15   16
 18   19   20   21   22     23   24 23 – End of 2nd Quarter        17   18    19   20   21   22   23
 25   26   27   28   29     30   31      43 Student Days           24   25    26   27   28   29   30
                                      26-30 Winter Break

174 Day Student Calendar                                       *Snow Make Up Days – Made up in the order listed here:
5 Inservice Days                                                May 16, May 17, May 18, April 5, April 9 and February 20
2 Comp Days
181 Teacher Contract Days




                                                               5
Accidents: The school makes every possible effort to provide an environment in which the
student will be safe from accidents. When accidents occur, first aid is administered then the
parent is notified. Further decisions and actions are the responsibility of the parent.

In case of an accident, the school requests that the parent provide for the school at least one other
person to be called. Medication is not administered by the school personnel unless proper
paperwork, from the parent, is on file.

Achievement Tests: Every year achievement tests are given. Students in grades 3-6 take the
NWEA (Northwest Evaluation Association) two times per year (fall and spring). This evaluation is
                  computer generated. The MCA (Minnesota Comprehensive Assessments)
                  are administered in April. This assessment evaluates reading and math. It
                  is very important that all children have 10 hours of rest and are present when
                  these tests are administered. Students need two #2 pencils and an eraser
                  for the MCA evaluation.

All students in grade 5 will take the Science MCA to assess their science skills.

Students in grades K-2 will take the TERRANOVA-3. The TERRANOVA-3 is a nationally
standardized achievement test for grades K-12. Students need two #2 pencils and an eraser for
the evaluation.

Test results will be given to parents as soon as possible. Parents are encouraged to call if they
have questions.

         Age Requirements: Minnesota State statutes require that kindergartners be five years
         old on or before September 1 of their kindergarten year.

Assignment Notebooks: All children in grades 1-4 will be provided with an assignment
notebook. Grade school assignment notebooks are a necessity for the organization of every
student. You can also use the planner to stay connected to the teacher by conveying information
to them in the planner and letting them know they can write notes to you as well. The planner
gives you an opportunity to casually check in with your student about the completion of their
homework, and gives you a chance to support and compliment their growing organizational skills.
Please sign your child’s notebook daily to inform teachers that you have read the
homework assignments and possible notes.

Attendance: Regular school attendance is the best way to assure that students receive the best
education. Our attendance policy is as follows (Policy #503): Please call when your child is going
to be absent/tardy.

1. As required by current statutes, regulations of the State Department of Education and the
School Board of this District, students shall be in attendance each school day that school is in
session.

2. Truancy or skipping, for purposes of this policy, is the absenting of one’s self from school or
class without the approval of the building principal;

3. Leaving school grounds without permission of school personnel shall be considered subject to
disciplinary action.

                                                  6
4. Students arriving between 8:15 and 9:59 will be counted tardy. If the student arrives after
10:00, they will be counted as absent for a half day. Students arriving late or leaving early MUST
sign in at the office.

5. Students leaving before 2:30 are counted ½ day absent. If they leave after 2:30, this is counted
as a tardy. Students MUST check out at the office when leaving early.

           Band: Beginning in 5th grade and continuing into 6th grade, students are required to be
          in band. Students will receive lessons during the school day. Information about the band
        program will be available to students and parents at the end of 4 th grade.

Bicycles/Scooters: Students are allowed to ride their bikes/scooters to school. All
bikes/scooters must be parked in the area where the bike rack is located in front of the school
building. The school is not responsible for bikes/scooters that might be stolen or damaged while
on school property. The wearing of helmets is encouraged.

Birthdays: There are special occasions when parents may send treats to school for the entire
class. If you would like to send a treat, we ask that you adhere to the State Department
guidelines, which state that such treats must be purchased from a bakery or store. All candies
should be individually wrapped. Homemade cookies, cakes, etc. are not allowed. Also, due to
students with a variety of health issues, it would be good practice to contact the teacher to see if
there are any special considerations you need to make when purchasing treats.

Please do not plan for any class parties or activity without making prior arrangements with the
teacher. In hopes of preventing students from feeling excluded or having hurt feelings, invitations
for personal parties should be mailed to those invited, not given out at school.

                           Box Tops: Hendricks Public School participates in the Box Tops for
                           Education program sponsored by General Mills. The school receives
                           $0.10 for each Box Top that is turned into the school. All Box Tops can
be placed in the collection box in the hallway near the office.

Bullying: In order to provide a safe and civil learning environment, Hendricks Public School
prohibits all acts of bullying. Bullying is defined as any written or verbal expression, physical act or
gesture, or pattern thereof, by a student, or group of students, that is intended to cause or is
perceived as causing distress to one or more students. It is the school’s intent to prevent bullying
and to take action to investigate, respond, remediate, and discipline those acts of bullying which
have not been successfully prevented. Any person who believes he/she has been the victim of
bullying or any person with knowledge or belief of conduct that may constitute bullying should
report the alleged acts to the building principal. Discipline may include, but is not limited to,
warning, suspension, exclusion, expulsion, or remediation. Disciplinary consequences will be
sufficiently severe to try to deter violations and to appropriately discipline prohibited behavior. The
complete district policy is available at the school.

Hendricks Public School District #402 is committed to maintaining an environment free of bullying
and intimidation. Bullying or intimidation means a pattern of conduct that substantially interferes
with student’s educational benefits, opportunities or performance that occurs in school, on district
property, on a school bus, bus stop, at a school activity, or at other locations that directly affect
school programs and activities. Bullying includes an intentional gesture, or a written, verbal or
physical act or threat that a reasonable person under the circumstances knows or should have the
effect of the following:

                                                   7
         Harming a student;
         Damaging a student’s property;
         Placing a student in reasonable fear of harm to his or her person;
         Placing a student in reasonable fear of damage to his or her property;
         Presenting a sufficiently severe, persistent or pervasive threat or action and creating an
          intimidating, threatening or abusive educational environment for a student.

Bus Transportation: For the safety of all bus riders, our School Board has adopted a Pupil
Transportation Safety Policy (#707). In the fall of the year a bus discipline policy is sent home to
each family. Copies of this policy are available at district office.

The 1994 Legislature made significant changes in the laws and rules governing pupil
                  transportation in Minnesota. One of the most significant changes may be
                     that the new law clearly states that riding a school bus is a privilege,
                            not a right, and that privilege can be suspended when students
                            do not comply with policies, rules, or laws. It also states that the
                           School District conduct and discipline policies apply to the school bus
                           and to bus stop areas as well as to school buildings and grounds. The
school bus is       an extension of the classroom. If a student is removed from the bus for
misbehavior, the suspension will also be for any co-curricular or field trips that would fall
with in the suspension period.

We urge parents to send notes to teachers and bus drivers if children are not to ride the bus
home. If we do not have a note or phone call from you, your children will be expected to ride the
bus home.

          The following are rules of conduct that should be observed by the students riding buses:

        Students must keep their hands, heads, and property, inside the bus.
        Students must not move about in the aisles or needlessly change seats in the bus.
        Students are to remain seated while bus is in motion.
        Ride only the bus you are assigned.
        Loud talking is distracting to the driver and is not permitted.
        Be prompt at the designated bus stops.
        Load in an orderly manner.
        Teasing, fighting, or use of unfit language will not be tolerated on the bus.
        Emergency doors must not be tampered with except in legitimate emergencies.
        Throwing articles of any kind in a bus is dangerous and will not be tolerated.
        Any damage to a bus should be reported to the driver at once.
        Any student disfiguring or mutilating a bus will be required to pay for the damage and may be
         suspended from riding the bus.
        Pupils must help to keep the buses clean, sanitary and orderly. Students who throw things on
         the floor of the bus may be assigned to clean up duties.
        Smoking, consuming alcoholic beverages or use of drugs is strictly prohibited and against the
                                       law.
                                    Students will be assigned and required to sit in their assigned
                                       seats at the bus driver’s discretion.
                                    Be helpful and courteous.

                               REMEMBER: Riding the bus is a privilege that can be refused at
                               any time if the rules are not observed.

                                                     8
School Bus and Bus Stop Procedures: The school district school bus safety procedures are to
be posted on every bus. The school district's discipline procedures are to be followed.
Consequences are progressive and may include suspension of bus privileges. It is the school bus
driver's responsibility to report unacceptable behavior to the school district's administration or
building designee.

   Penalties for Infractions on the bus

   1. First Offense         verbal warning by the bus driver.

   2. Second Offense        written report from the bus driver and a phone call to the parents from
                            bus driver.

   3. Third Offense         parent meeting to discuss future bus privileges.

   4. Fourth Offense        parent’s responsible for 1 week of transportation NO BUS privileges.

   5. Fifth Offense         parent’s responsible for 3 weeks of transportation NO BUS privileges.

       If a student is suspended from the bus; his/her parent(s) will be required to furnish his/her
       transportation to and from school during the entire period of suspension.

Crisis Management: Hendricks Public School #402 has a Crisis Management Policy. In the event
of such occurrences (examples: severe weather, fire, bomb threats, hazardous materials,
intruders, or other situations affecting safety) building staff will direct students, staff, and visitors
where to move and what to do to ensure the safety of all.

Confidentiality: Hendricks Public School #402 is committed to meeting the provisions of the
Family Education Right and Privacy Act. (FERPA)

Statement of Rights

Parents and eligible students have the following right under the Family Educational Rights and
Privacy Act:
1. The right to inspect and review the student’s educational record.
2. The right to exercise a limited control over other person’s access to the student’s educational
record.
3. The right to seek to correct the student’s educational record.
4. The right to report violations of FERPA or policy to the Department of Education.
5. The right to be informed about Family Educational and Privacy rights.

Definitions:
    Student: Any person who attends or has attended an instructional program sponsored by
        Hendricks Public School.
    Eligible Student: A student or former student who has reached the age of maturity.
    Parent: Either natural parent – unless his/her rights have been revoked by a court, or an
        individual acting as a guardian.
    Personal Identifier: Any data or information which makes the subject of the record known,
        such as name, family, address, social security number, and other information which related
        directly to identification of the student.


                                                    9
Educational Records: Any record maintained by District #402 which is related to the student
except for the following:
1. Personal note by a staff member to be used as a memory aid.
2. A school employment record if the student has been an employee of the school.
3. Alumni records which relate to the student after he/she is no longer a student.

Daily 5™: Daily 5™ is a series of literacy tasks which students complete daily while the teacher
meets with small groups or confers with individuals. Hendricks Public School will be incorporating
Daily 5 with Guided Reading to enhance our current basal reading series. The Daily 5™ is more
than a management system or a curriculum framework – it is a structure that will help students
develop the daily habits of reading, writing and working with peers that will lead to a lifetime of
independent literacy.

Discipline Procedures/Plan: The following procedures will be used in conjunction with District
#402’s Discipline Policy #506 in the policy reference manual in the office. It is the position of
Hendricks Public School Elementary that fair discipline procedures will contribute to the quality of
our students’ education. Good citizenship is largely a matter of being respectful and courteous.
School discipline should provide for the safety of staff and students and ensure an academic
environment conducive to learning for all students. Most students attend school with the attitude of
embracing the educational experiences. Others may have behavioral issues that are blocking or
interfering with their own or other’s educational experience. Our school has a responsibility to
address these issues so that all students can learn. Our focus is on providing the following:
        •expectations and consequences must be clearly communicated to teachers, parents, and
        staff and;
        •fair and consistent enforcement of the consequences must be maintained.
If a child chooses not to follow our basic rules there will be consequences. Disciplinary measures
will be a consequence of improper actions. We have three basic behavior expectations of
Hendricks Public School. We expect them to conduct themselves in a safe manner, be
respectful, and to act responsible.

      Elementary students must recognize and respect the rights of others

   Student Responsibilities: All Students have the responsibly:
    For their behavior and obeying school rules, polices, and procedures
    To attend school daily, except when excused, and to be to on time
    To purse and attempt to complete the courses of study prescribed by the state and local
      school boards
    To make necessary arrangements for making up work when absent from school
    To respect and maintain the school’s property and the property of others
    Refrain from indecent or obscene language during school day, free play, on bus, and at all
      school events
   Students should conduct themselves in an appropriate physical or verbal manner:
    Acts disruptive of the education process, including, but not limited to, disobedience,
      disruptive or disrespectful behavior, defiance of authority, cheating, insolence, and
      insubordination
    Using, possessing, or distributing items or articles that are illegal or harmful to person or
      property
    Possessing distributing weapons, or look-alike weapons or other dangerous objects
    Possession of nuisance devices or objects which cause class room distractions and may
      facilitate cheating including but limited to pagers, radios, phones, including picture phones
    Sexual and/or racial abuse and/or harassment
                                                 10
   Committing an act which inflicts bodily harm upon another person, including fighting or any
    assaultive behavior which cause or could cause injury or endangers the health, safety, or
    welfare of teachers, students, other district personnel
   Hendricks Public students must recognize and respect the rights of others

Disciplinary Action: Consequences are determined by the teacher and administration.
 It is the general policy of the school district to utilize progressive discipline to the extent
   reasonable and appropriate based upon the specific facts and circumstances of student
   misconduct. See Hendricks Public Disciplinary Action Plan on next page.

Dress Code: The staff and Board of Education of the Hendricks Public School seek the
cooperation of all parents in the manner of proper dress and appearance of students. We are
sincerely convinced that there is a direct correlation between a child’s dress and attitude.
Students will not wear clothing which is offensive, promotes alcohol, drugs, or tobacco products
while in the building or at school sponsored activities or events. Students wearing such apparel
will be required to call home for a change of clothing, be asked to turn the article inside out, be
required to change into clothing provided by the school office, or will work in an alternative
location for the day. (Policy #504) Please make sure that your child is suitably dressed for the
weather. We require that children wear warm clothing during the winter months
including: coat, snowpants, hat, mittens or gloves, and boots. Children are outside daily
unless the temperature or wind chill is below zero, or it is raining hard.

Free Play Winter Clothing rule:
 Students need to have their coats on and the coats need to be zipped.
 If it is windy, it is recommended that students have their hood up or hat on.
 Boots, mittens and socks will not be required until it snows; although, it is recommended
   that mittens and socks be worn.
 When it snows: socks, boots, hats, mittens, and snow pants are required.

Our policy is if children are well enough to be in school, they are well enough to be outdoors,
so be sure they are dressed appropriately.




                                               11
                  Hendricks Public Elementary Disciplinary Action Plan


         Minor/Level 1                       Minor/Level 2                        Major/Level 3
    Addressed by teacher in       Addressed by teacher in classroom        Must involve administrator.
      classroom or hallway          or hallway. Pink form signed by       (referral to office – recorded)
  (non-referral – non-recorded)                 parents.
                                  (non-referral – recorded pink form)

1. Inappropriate Language         1. Inappropriate Language             1. Inappropriate Language
     Swearing                         Harassment (taunting)                Excessively vulgar
     Name calling                     Threats/intimidation                   language
     Verbal argument                                                        Severe verbal threats
     Negative comments           2. Physical Contact                          against anyone
     Impolite Language                Kicking                              Sexual harassment
     Talking back/lying               Spitting                             Racial harassment
                                       Play fighting resulting in an        Bullying
2. Physical Contact                      injury
     Pushing/shoving                  Slapping                        2. Physical Contact
     Bumping                          Hitting others                       Physical intimidation of
     Touching someone else                                                    faculty/staff
                                  3. Defiance                                Sexual assault
3. Defiance                            Arguing with others and not          Fighting/Physical assault
    Stubborn behavior                    complying with redirection
    Breaking class rules              Defiance of verbal              3. Defiance
    Talking back                         directions                         Walking out of
    Lack or participation             Running away from                       classroom
                                          situations                         Leaving your class while
    Missing homework
                                                                                in the hallway
                                  4. Disruptions
4. Disruptions
                                       Inappropriate use of space
     Making noise
     Yelling out
                                  5. Property Misuse
     Disruption during
                                       Throwing objects
       instruction
                                       Destruction of peer, teacher
     Constant talking
                                         or school property
     Crying

5. Property Misuse
    Ripping books
    Breaking pencils,
      crayons, or classroom
      toys
    Throwing small objects
    Pushing furniture
    Writing on desk, books
    Going into another
      person’s desk and/or
      backpack

6. Inappropriate Behavior
     Inappropriate behavior in
       bathrooms




                                                  12
Drug Free: Tobacco, alcohol, and chemical use are strictly prohibited on school grounds which
includes the school parking lots and buses.

            Electronic Devices: Hendricks Public School highly recommends that all
            electronic devices not be brought to school. Such items include, but aren’t limited
             to pagers, CD players, cellular phones, two-way radios, and iPods. Students may
              bring the devices to school as long as students are using it appropriately; however,
              the school will not be responsible for items brought to school which are not required
by the classroom teacher. Should damage or loss occur, it will be the responsibility of the
parent/guardian to personally resolve the matter.

Equal Opportunity/Discrimination: It is the Policy of Public Schools to not discriminate on the
basis of age, national origin, race, religion, handicapping condition, or sex, and that all students
will be encouraged to participate in school activities.

                Field Trips: Field trips are scheduled in some grades throughout the school year
                  to enhance the educational curriculum. These trips are not a requirement, but
                   a privilege. Any child, who does not meet the classroom teacher's
                   standards for behavior, grade level expectations, attendance, academic
                  effort, or homework, can and/or will be excluded from the field trips and
extracurricular activities. If a child is not allowed to participate, contact will be made by the
teacher with the parent prior to the trip and other classroom arrangements will be met. In order for
any child to participate in a field trip experience, the school must have a permission form signed by
the parent or guardian. These permission slips will be sent home with your child on the first day of
school to be signed and returned.

         Fire Drills and Tornado Drills: Safety procedures in the event of tornado or fire are
         discussed and practiced periodically at school. A written procedure is posted in each room
         of the school. We ask parents to impress upon their child the importance of these drills.
         The children will be instructed on how to evacuate the building in case of fire and will
         receive periodic drills to insure that children know how to react in case of a fire
         emergency.

      Keep calm and quiet.
      Follow exit direction posted in classroom.
      When in hallways or in bathroom, use nearest exit.
      Walk single file, quickly and quietly. Do not run.
      First person out holds the door for all people.
      Wait for all clear signal before re-entering the building.
      First person holds the door for all people.
      Return directly, quickly and quietly to classrooms. Do not run.

In the event of a tornado, all students will be familiar with the general areas of the building that
have been designated as tornado shelters and with tornado procedures.

      Keep calm and quiet.
      Follow tornado drill procedures as directed.
      When in hallways or in bathroom, go to your assigned area. Sit along the edge of the wall
       in a protective position.
      Walk single file, quickly and quietly. Do not run.
                                                   13
       Wait for all clear signal before returning to classroom.
       Return directly, quickly and quietly to the classroom. Do not run.

Lock-down, bomb threats, hostage, and shooting procedures are in place.

Fire Alarm /Fire Extinguisher / Dialing 911: Tampering with a fire alarm, fire extinguisher, or
dialing 911 is dangerous and against the law. Anyone turning in a false alarm will be prosecuted
under Minnesota State Statutes. Matches or lighters are not to be in the building or on school
grounds.
Fundraising Guidelines: All fundraising activities must be approved by the Hendricks Public
           Elementary administration.
              Grading System: During the 2011-2012 school year, Hendricks Public Elementary
              School (Kindergarten – 4th) will using a new reporting system. The purpose for the
              new report card is to inform students and parents about a student’s performance on
              the grade level standards. The new report card measures progress against a uniform
              standard, rather than other subjective assessments. Information related to growth
              and overall strengths and needs is captured in the teacher comment section.

Level 4 – Extends targeted grade level standards: represents the student exceeding grade
level expectations set by the state and that a student will be successful in the next grade or quarter
and whose curriculum may be enriched.

Level 3 – Demonstrates proficiency of targeted grade level standard: represents the student
meeting the grade level expectations set by the state and indicates that a student has the
necessary skills and concepts to be successful in the next grade or quarter.

Level 2 – Inconsistent and needs support to meet targeted grade level standards: indicates
that the student has not yet met grade level expectations set by the state and that a student does
not have the necessary skills and concepts to be successful in the next grade or quarter. This
should alert parents that close communication is needed for further student support. For example:
If the student seldom turns in math homework and does not cooperate in-group problem solving in
math, this student’s work habits and conduct grade may indicate Level 2.

Level 1 – Insufficient performance of targeted grade level standards with support: indicates
that the student has not yet met grade level expectations set by the state and that a student does
not have the necessary skills and concepts to be successful in the next grade or quarter. This
should alert parents that close communication is needed for further student support.

Grades 5-8 will use a letter grade system.
Grade                Percentage    Grade              Percentage
 A                    96-100        C                   82-84
 A-                   94-95         C-                  80-81
 B+                   92-93         D+                  78-79
 B                    89-91         D                   76-77
 B-                   87-88         D-                   75
 C+                   85-86         F                   Below 75

Guided Reading: Guided reading is one component of the shared reading block during which the
teacher provides support for small, flexible groups of beginning readers. The teacher helps
students learn to use reading strategies, such as context clues, letter and sound knowledge, and
syntax or word structure, as they read a text or book that is unfamiliar to them. The goal of guided
                                                  14
reading is for students to use these strategies independently on their way to becoming fluent,
skilled readers.

Gum, Pop, etc: Gum chewing will be permitted to all students at the teacher’s discretion. Cough
drops and throat lozenges are acceptable when needed. However, no sunflower seeds will be
allowed. Pop will not be permitted in hallways; however, may be allowed in junior high and high
school classrooms at teacher’s discretion. All pop is required to be in a bottle with a top.

Harassment: Students that engage in physical, mental, or verbal behavior that ridicules, taunts,
or demeans other students or staff will be subject to disciplinary action.

Sexual harassment is a form of sex discrimination, which violates Section 703 of Title of the Civil
Rights Act of 1964, as amended, 42 U.S.C. 2000 et seq., and MN Stat. 363-01-14, the Minnesota
Human Rights Act. .It shall be a violation of this policy for any student or staff of Hendricks Public
School to harass another student or any employee through conduct or communication of a sexual
nature as defined by the statute.

It is the practice of Hendricks Public School to maintain a positive and safe learning and working
environment that is free from sexual, religious, or sexual harassment or violence. ISD #402
prohibits any form of religious, racial, or sexual harassment and violence. It shall be a violation of
this policy for any pupil, teacher, administrator, or other school personnel through conduct or
communication of a sexual nature or regarding religion and race as defined by this policy. (For
purposes of this policy, school personnel include school board members, school employees,
agents, volunteers, contractors, or persons subject to the supervision and control of the district.)

The school is required to investigate and report all complaints, formal or informal, verbal or written,
of racial, religious, or sexual harassment or sexual violence, and to discipline any student or staff
member who is found to have violated this policy (Policy #413).

Copies of District Policy #402 regarding Sexual Harassment are available in the office.

Hazing: Hazing means committing an act against someone else or helping another person
commit an act that creates a risk of harm, threat, intimidation or mental or physical discomfort.
Examples of hazing could include: inflicting extreme mental stress, embarrassment or humiliation;
inflicting severe physical stress such as exposure, confinement, fatigue or any activity which has
an unreasonable risk of harm. Any hazing activity needs to be reported with school officials
investigating the action and impose disciplinary action upon the offender(s). Copies of the Hazing
Policy (#526) are available at the district office.

                                               HEALTH PROCEDURES

                School Nurse: The school nurse will be at the school daily. The school nurse will
                do Health screening, maintain health records, give medication, immunizations, and
                provide health education and health care to students and staff. Please contact the
                nurse for any concerns you may have about your child’s health.

                 Health Services/Medication: If a student becomes ill in school, he/she should
                 report to the school nurse (or office, if nurses not available). Presently the district
                 follows these procedures: A student complaining of feeling ill and having
temperature of 100 degrees will be sent home. This temperature may indicate a minor illness but
it could be early symptoms of a severe illness with the risk of exposing others to a contagious

                                                   15
disease. Occasionally a below normal temperature with symptoms will also be an indication that a
student should be sent home.

Parents will be called when students have inflamed eyes or the possibility of pink eye. Any student
having a lesion that resembles impetigo (staph infection) or ring worm must be excluded until
medical attention is received. All students with questionable rashes must be excluded until the
possibility of a contagious disease can be decided upon.

The school nurse will call parents as needed and students are not to leave the building without
permission.

All prescription medication given at school must be stored in the nurse's office. The prescription
must be in the original, labeled container and be accompanied by 1) a doctor's written order, 2)
assigned written permission from the parent/guardian to dispense medication, 3) a slip enclosed in
the bottle indicating the number of pills sent.

                Children who have prescribed inhalers for asthma or reactive airway disorders may
                possess and use as prescribed in school, provided the following requirements are
                met: 1) parent must provide an annual written authorization, 2) the inhaler must be
                properly labeled for the student, and 3) the school nurse must annually assess
                student’s knowledge and skill level to possess and use in school settings.

Over the counter medications must be stored in the nurse's office and may only be dispensed by
the school nurse. These medications must be in the original container and accompanied by written
authorization from the parent/guardian.

Any medications and medication permission forms transported to school should be left in the office
upon entering the building. For safety reasons, students should not be carrying or storing
medications in their lockers, school bags, or pockets (asthma inhalers excluded).

Medication: If your child needs to take a doctor's prescribed medication during school hours, the
school must have a signed authorization from the parent and physician (giving the school
authorization to administer prescribed medication during school hours). The medication must be
in the prescribed bottle. Please ask the pharmacist to divide the prescription, one bottle for home
and one for school use. The bottles must contain the name and telephone number of the
pharmacy, the pupil's identification, name of the physician, and dosage of the drug to be given.
Health and safety of the student is a primary concern. An authorization form for all medications,
along with the bottle of medication, will now be required for all medications. This is the policy the
Minnesota Department of Health requires.

If your child brings non-prescription (this includes Tylenol) medication to school, it will have to be
accompanied by an authorization explaining the reason, when to give the amount that you sent
along, and turned over to the staff for administration.

You can request medication authorization forms from the school office or check our
website if you wish to keep some on hand. A copy of the prescription or a hand written note
is NOT authorization. We must have the form giving the school authorization to administer.




                                                   16
                                          Hendricks Public School District
                                                               2011-2012
     AUTHORIZATION FOR ADMINISTRATION OF PRESCRIPTION
                                         MEDICATION AT SCHOOL

Name of student: ___________________________________ Birthdate ____________


Medical            Medication            Strength              Dose                  Time                 Route                Possible
Condition                                                                                                                      Side Effects




        Other Considerations Directions:

Start Date: ____________________________ Stop Date: _______________________
                          (All authorizations expire at the end of the school year)

(Changes maybe called to the school nurse by physician with written confirmation within 24 hours) (Faxes acceptable)

____________________________________                                           ______________________________
Print of Type Name of Physician/Licensed Prescriber                            Physician's/Licensed Prescriber's Signature

        ____________________________________                                   _____________                  __________
        Clinic Address                                                         Phone Number                   Date


                                        PARENT/GUARDIAN AUTHORIZATION
1.      I request that the above medication(s) be given during school hours as ordered by this student's physician/licensed prescriber. I also
        request the medication(s) be given on field trips, as prescribed.

2.      I release school personnel from liability in the event adverse reaction result from taking the medication(s).

3.      I will notify the school of any change in the medication(s), (ex: dosage change, medication is discontinued, etc.)

4.      I give permission for the school nurse to communicate with the student's teachers about the student's health condition(s) and the action
        of the medication(s).

5.      I give permission for the school nurse to consult with the above named student's physician/licensed prescriber regarding any questions
        that arise with regard to the listed medication(s) or medical condition(s) being treated by the medication(s).

6.      I give permission for the medication(s) to be given by designated personnel as delegated by the school nurse.



        ____________________                               _______________________                            ____________________
        Date                                               Parent/Guardian Signature                          Relationship to Student


                                                                      17
                       Hendricks Public School District
                      REQUEST AND AUTHORIZATION FOR
              NON-PRESCRIPTION MEDICATION
                        2011-2012

Name of Student __________________________________ Birth date _________________

Address _________________________________________ Telephone ________________

Parent/Guardian Name _______________________________________________________

School ___________________________________________ Grade ____________________


WE ENCOURAGE MEDICATION BE ARRANGED OUTSIDE SCHOOL, IF POSSIBLE.


Name of medication ________________________________________________________________

Dosage time of administration ________________________________________________________

Duration (week, month, etc) __________________________________________________________

Precautions, reactions, other side effects to watch for: ______________________________________

_________________________________________________________________________________

Condition being treated ______________________________________________________________



                              Parent Statement
____ I request and authorize the school nurse or personnel
designated by the school to administer medication to the above
student as stated. I understand the medication must be provided in a
container with the appropriate label intact.


       ______________________________________________          _______________________
                 Parent/Guardian Signature                             Date



                                          18
              Vision Screening: All students in Pre-school, 1st, 3rd, 4th and 5th grades are
              screened yearly as recommended by the Minnesota Department of Health. Visual
              acuity, color vision and muscle balance are screened. Students with potential vision
              problems are rescreened. Referral letters will be sent to parents if necessary.
              Students with vision problems are given preferential classroom seating.

               Hearing Screening: All students in Pre-school, 1st, 3rd, 4th and 5th grades are
               screened yearly as recommended by the Minnesota Department of Health. A
               Tympanogram, to measure middle ear function, is done on the younger students.
               Referral letters will be sent to parents as necessary. Further testing can be done
               without cost at SW-WC Central Service Co-op in Marshall. Students with hearing
               loss are given preferential classroom seating.

Scoliosis Screening: All 5th grade girls are screened for scoliosis. If necessary, a follow up
screening will take place during 6th grade.

Illness at Home: If your child has been sick, please consult the following list to see if your child
should stay home:
              If your child has or has had a fever of 100 degrees or more, he/she should stay
               home for 24 hours after the temperature returns to normal without use of
               medication.
              If your child has vomited or had diarrhea, he/she should stay home until 24 hours
               after the last episode and is able to hold down a meal.
              If your child has any rash that may be disease related or you do not know the
               cause, check with your family doctor before sending him/her to school.
              If you have any questions, please call your family doctor or the school nurse.

Illness at School: If your child becomes ill while at school we will make every effort to contact the
parents. If we are unable to reach a parent, we will notify the person you have listed as an
emergency contact on the Registration Card. If we are unable to reach anyone, we will keep the
child as comfortable as possible until we are able to contact someone. If emergency treatment is
needed and we cannot contact anyone listed on the Registration Card, we will notify your family
physician or contact 9-1-1.

Immunization Policy
In order to enroll or remain enrolled in any elementary or secondary school in Minnesota, the
parent/guardian of a student must have a statement on file with the school administrator or other
person having general control and supervision of the school that shows that the student is either:

a. immunized against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, hepatitis B,
and varicella, or

b. immunized against measles, mumps, rubella, and varicella and has begun, but not yet
completed, immunizations against diphtheria, tetanus, pertussis, and/or polio, and/or hepatitis B,
as verified by a provider or clinic, or

c. legally exempt from one or more of the required immunizations, as evidenced by either a
statement of medical exemption signed by a provider, a notarized statement of conscientious
exemption, or, in the case of varicella disease, provider-documented history of varicella disease.
[Note: Before September 2010, a parent can document history of varicella disease.] See Minn.
Stat. Sec. 121A.15, subd. 1 and 3.

                                                 19
http://www.health.state.mn.us/divs/idepc/immunize/school/schimmzlawqa.pdf.

Head Lice: Head lice can be a problem in schools and you will be notified if a problem occurs.
Students can return to school after treatment for the lice and after inspection by the school nurse
to assure that the treatment was effective.

Homework: Homework is important. It is an extension of the learning that takes place in school.
It can and should provide practice and drill that reinforces classroom learning or provide
                                opportunities for independent study, research and creative thinking.
                                Homework will vary according to grade level and individual children’s
                                needs. Parents can help best by arranging a quiet, comfortable
                                place for their children to work and by seeing that assignments are
                                completed. Your child should be responsible for getting their
                                assignments written down accurately so that teachers need not be
                                contacted about assignments. In addition, all students will have an
                                assignment notebook that will be filled in daily. Most homework is
                                due the next day at class time for that subject. Anyone whose
work is not done at class time must have it finished and handed in by the end of the school day or
could be asked to stay after school to complete it. If the work is not completed then and handed
in, it will be a zero. The student will call home before school is out if they have to stay after school.
Further discipline will be conducted at the discretion of the teacher when homework is repeatedly
not completed. See fieldtrip policy. (This guideline does not apply to students who have been
absent from school.) Sometimes make-up work from absences becomes a problem. When a
student has missed several days due to an illness or a vacation, the teacher may specify certain
assignments to be done at specific times so they are not waiting until the last make-up day to hand
everything in at once. The rule of thumb for homework time load is 10 minutes for each grade.

After School Program is offered Monday – Thursday from 3:35 pm – 5:15 pm. Students
attending must stay the entire time unless picked up by a parent. The shuttle bus will be available
during this time. In the event of a holiday, there is no afterschool program.

Internet Acceptable Use Policy

Responsibility of Internet Use: Users are prohibited from using school district Internet resources
or accounts for the following purposes:
       To access, upload, download or distribute pornographic, obscene or sexually explicit
         material.
       To transmit or receive obscene, abusive, or sexually explicit language.
       To violate any local, state, or federal statute.
       To vandalize, damage or disable the property of another person or organization.
       To access another person's materials, information, or files without direct permission of
         that person.
       To violate copyright laws, or otherwise use another person's property without the
         person's prior approval or proper citation, including the downloading or exchanging of
         pirated software or copying software to or from any school computer.
       Unauthorized commercial use or financial gain.
       Goods and services can be purchased over the Internet that could potentially result in
         unwanted financial obligations and that any financial obligation incurred by a student
         through the Internet is the sole responsibility of the student or the student's parents.



                                                   20
                        INTERNET ACCEPTABLE USE AGREEMENT
                                     2011-2012
STUDENT

I have read the school district policies and guidelines for acceptable use of the Internet and agree to abide by
them. I further understand that any violation of the regulations above is unethical and may constitute a
violation of law. Should I commit any violation, my access privileges may be revoked, school disciplinary
action may be taken, and/or appropriate legal action may be taken.

Student’s Full Name (Please Print): ____________________________________________

Student’s Signature: ___________________________ Date ________________________


PARENT OR GUARDIAN

As the parent or guardian of this student, I have read the school district policies and guideline for Internet
Acceptable Use Agreement, and I understand that this access is designed for educational purposes. The
School District has taken precautions to eliminate controversial material. However, I also recognize it is
impossible for the District to restrict access to all controversial materials and I will not hold them responsible
for materials acquired on the network. Further, I accept full responsibility for supervision when my child’s
use is not in a school setting. I herby give permission to issue an account for my child and certify that the
information contained on this form is correct.

Parent’s/Guardian’s Name (Please Print): ____________________________________________

Parent’s/Guardian’s Signature: ___________________________ Date _____________________


SUPERVISING TEACHER

(Must be signed if the applicant is a student)
I have read the school district polices and guidelines for the Internet Acceptable Use Agreement and agree to
promote these policies and guidelines with the student. Because the student may use the network for
individual work or in the context of another class, I cannot be held responsible for the student’s use of the
network. As the supervising teacher, I do agree to instruct the student on acceptable use of the network and
proper network etiquette.

Teacher’s Name (Please Print): ___________________________________________________

Teacher’s Signature: ________________________________ Date _______________________




                                                       21
Paperless: Due to environmental and economic concerns, Hendricks Public School will be
sending home notes and classroom newsletters via email again this year.


                       HENDRICKS PUBLIC SCHOOL

              Are you able to go paperless with school notes?
              Hendricks Public School will be using email to
             send notes and newsletters home again this year.


            Please fill in your name and e-mail address below
            and return this form to your classroom teacher by
                              August 30, 2011.

If you are unable to go paperless, please check the box below and we
            will make sure that you receive paper copies.

NAME____________________________________________________
GRADE: _________________________________________________
PARENT/GUARDIAN NAME: ______________________________

E-MAIL ADDRESS_________________________________________

□    I am not able to go paperless.


We will make every attempt to keep your email information within
the school (sharing it only with classroom teachers and
administration).

Thanks for your cooperation.

Shelly Jensen
Principal


                                             22
Sanctions: Violations of the Hendricks Public School Internet policy shall result in one or more of
the following sanctions:

          Loss of Internet use privileges.
          Additional disciplinary action consistent with the discipline policy as stated in the student
           handbook.
          Referral to the appropriate law enforcement agencies.

Jewelry Policy: The policy for the Hendricks Public School and Jr. High School Physical
Education, Free Play and other activities is that no jewelry will be worn during these activities. This
policy is strictly for the safety of all children involved.

Leaving School during the day: Please attempt to schedule the appointments either before or
after school or on days when school is not in session. However, when it is necessary for your child
to be excused during the school hours, we ask that a note be sent with your child about the
request to leave and time. Please come to the office to sign your child out.

Lockers: Lockers are school property, and the lockers and their contents may be searched for
health and safety reasons. All students will be assigned a locker at the beginning of the school
year. Some students will share lockers with another student. Students may not put locks on their
lockers. Due to the size of lockers, only coats, hats, boots, etc. should be left in a locker. School
supplies should be kept in the classroom. Toys and valuables should never be left in lockers, as
they are not secured with a lock.

Lost and Found: It is important to label your child’s items with their name. Throughout the
school year, we acquire a large amount of items in our lost and found. The lost and found is
located in the copy room directly across from the cafeteria. We welcome you to check for missing
items in the Lost and Found. Also, please encourage your child to check for lost items. At the end
of the school year, leftover lost and found items are donated to a charity organization.

                                                           Lunch and Breakfast Prices
                                                         Student Lunch                $2.05
                                                         Student Breakfast            $1.20
                                                         Adult Lunch                  $3.30
                                                         Adult Breakfast              $1.50
                                                         Reduced Price Lunch          $ .40
                                                         Extra Milk                   $ .40
                                             Students are required to prepay money into their lunch
                                             account. They may prepay as much as they wish. As
                                             students go through the lunch line, their account will be
                                             debited for the proper charge.
We are on a computerized accounting program so children do not handle lunch tickets. This same
account also pays for breakfasts.
Students who bring their lunch may purchase a half pint of milk for 40¢. Students who purchase
school lunch may purchase an additional half-pint of milk for 40¢.

Free and Reduced Lunches and Breakfasts
Children who may be eligible for free and reduced priced meals can have their parents complete
the application forms available in the school office. Students who were eligible at the end of the
                                                   23
2011-2012 school year will remain eligible until October 1, 2012 by which time they need to re-
apply. We do recommend that you fill them out and send them when you receive them in the mail.
If a family's financial situation changes during the school year, families may apply for free and
reduced meals at any time during the school year. Applications are available from the office and
are considered confidential information.

Media Learning Center
   Books: Books may be signed out for 1 week and may be renewed if no one else has
      requested them.

      Magazines: Current issues may not be signed out; back issues may be signed out for 1
       week.

      Reference Books: May be checked out overnight, but they must be returned first hour the
       following morning. Current issues of encyclopedias may not be checked out over night.
       However, they may be checked out to the classroom for 1 or 2 hours.

      Paperbacks and Tapes: Cassette recordings and paperbacks can be checked out the
       same as books.

      Use of Library: Students using the library will be denied library privileges if they are being
       disruptive or disturbing other students.

Minnesota Comprehensive Assessments (MCA-II): The MCAs-II are 3rd-8th grade tests that
measure how well a student has mastered the Minnesota Academic Standards in math and
reading. Students do not pass or fail these tests. The MCA-IIs are part of the educational
accountability system in Minnesota. Schools will use these results to make curricular and
instructional decisions for all students. Additionally, there is a MCA-II test in science for 5th grade
and 8th grade students.

MCA-IIs are given in the spring of the year. Please be sure to watch our calendars for the dates of
the assessments. It is extremely important that your child be in school on those testing days.
When the results are received, you will be notified of your child’s individual test results and group
information about how all children performed.

Nuisance Articles: The possession or use of articles that are a nuisance, illegal, or that may
cause harm to persons or property’s prohibited at school, on the bus, and/or school sponsored
activities. Included, but not limited to squirt guns, toys, spray bottles, fireworks, spray paint, pagers
in class, compact disc/cassette players, lasers, and other nuisance articles in school will result in
confiscation of such articles, and possible disciplinary action.

Parent-Teacher Conferences: Parent-Teacher conferences will be held for all students in the
fall. This contact gives the parents and teachers a chance to discuss the child's growth and to
plan cooperatively to meet his/her needs. All parents will be contacted every quarter to inform
them of their child’s academic performance. The spring conferences will be by invitation or
request from parents.

Communication with parents concerning a student's academic performance is an essential part of
any student's assessment program. The school will keep parents informed if any problems arise
with the student's academic program or with the student's behavior. We encourage parents to talk
to their child's teacher if concerns arise. In almost all situations, problems can be resolved at the

                                                   24
parent-teacher level. It is important to remember that we are all working toward the same goal that
is to give the student the best education we can.

Parent Volunteers: For the last several years, we have had a number of parents who have
helped in many ways. This year we hope to enlist more parent volunteers. If you are interested,
please contact your child's teacher or the school office. Everyone has a talent that would be
valuable in the education of the children. Additionally, individual teachers may ask you to work on
a specific classroom project.

Pets Visitation Policy: For health and safety reasons, domestic and/or wild pets should not be
brought to school. However, if a pet is brought in for special reasons the classroom teacher needs
to be notified prior to the arrival of the pet so they follow up with the school nurse on students with
allergies. If the pet does come to school it can stay a limited time and must be in the owners
control at all times.

Pictures: School pictures are taken in the fall of each year. Students who don’t wish to buy
pictures still need to have their photo taken for use in school records and the yearbook. Spring
pictures are also taken of each student. These pictures are sent home, and parents can purchase
some, all, or none of the package. Pictures not purchased must be returned to the school.

Parent-Teacher Organization (P.T.O.): Hendricks Public School has an active P.T.O. that meets
monthly throughout the school year. The P.T.O. is made up of parents and teachers who are
seeking to assist with many different activities within the school. They are actively involved in
fundraising, volunteering, and assisting with different classroom projects. If you are interested in
attending a meeting, please call the school to see when the next meeting is scheduled.

Public Complaints about School Personnel: Whenever a complaint is made directly to the
board as a whole or to a board member as an individual, it shall be referred to the school
administration for study and possible solutions.

The following guidelines are the proper procedures to be followed by persons with questions or
complaints:
   1. Matters concerning a student should first be addressed to the teacher.
   2. Unsettled matters from (1) above or problems and questions concerning the system should
       be directed to the principal of the school.
   3. Unsettled matters from (2) above or problems and questions concerning the system should
       be directed to the superintendent.
   4. The board will consider hearing citizen complaints when they cannot be resolved by the
       administration. Matters referred to the board must be in writing and should be in
       terms of the complaints that have not been explored at eh appropriate administrative
       level.
   5. If necessary, the administration, the person who made the complaint, or the employee
       involved may request and executive session of the Board for the purpose if further study
       and decision by this body. Generally all parties involved, including the school
       administration, shall be asked to attend further explanations, and clarifying of the issues.
       Hear-say and rumor shall be discounted as well as emotional feelings except those directly
       related to the facts of the situation.
   6. Parents of students experiencing homelessness may dispute an action or policy of the
       school district in the same manner as other issues.
   7. If all options have been exhausted and there is no resolution, the final step would be to take
       the issue to the Minnesota Department of Education.
   8. This policy also applies to all Federal programs.
                                                  25
Registration Cards: At the beginning of the year, we have each child fill out a Registration Card
for our use if your child is ill or when we have early school closings. It is very important that you fill
out the registration card as completely as possible and send it back to school as soon as possible.
If any of the information on the Registration Card changes, please notify us so we can make the
necessary changes.


2011-2012 ISD 402 HEALTH & EMERGENCY INFORMATION
Date: __________ Custody Issue ___       Resides with Both                     Teacher _______________________
                     See back side if checked                                   Mom         Dad                                   Health Issue ____
                                                                                                                                  (Office Use Only)

Name __________________________________________Grade ____ Gender ___ Birthdate ________________
                Last (Legal)                   First           Middle
Address: ___________________________________________________ Home Phone Number: _____________________
          (RR and/or Box #)                       (City)          (Zip code)
____________________________________________________________________________________________________________________________
Father/Guardian Student Resides with (Print)                       Place of Employment                        Work Phone number or Cell/Pager


____________________________________________________________________________________________________________________________
Mother/Guardian Student Resides with (Print)                       Place of Employment                         Work Phone number or Cell/Pager


_____________________________________________________________________________________________________________________________
Name of Non-Custodial/Biological Parent (Print)                     Address                                      (Area Code) Day Phone Number
_____________________________________________________________________________________________________________________________
Emergency contact(s) if Parent(s) cannot be reached. (Print)       Relationship                                  (Area Code) Day Phone Number
_____________________________________________________________________________________________________________________________


Please list any health concerns, problems, or restrictions that should be brought to the attention of the nurse. _______________________________________


_____________________________________________________________________________________________________________________________


Race/Ethnicity ______________________________


E-mail address__________________________________ Parent/Guardian Signature ___________________________________



Report Cards: Report cards are issued at the end of each nine weeks. They will be handed out
during the week immediately following the grading period. Progress reports will be mailed home to
all students during the fifth week of each nine-week grading period in grades Kindergarten – 6th.

Retention/Promotion: The promotion of a student from one grade level to the next for the
elementary school shall be based primarily on the successful completion of work and appropriate
attendance required at the specific grade level of the student. It will be the individual classroom
teacher’s responsibility to have discussed with the school’s administrator the promotion of any
student not on grade level.
       When retention is recommended, it should occur at the earliest possible time in the
student’s school career. The primary consideration for grade assignment shall be successful
achievement in reading, math, spelling, and language and have appropriate attendance according
to school policy. Other factors such as the student’s ability to learn, social and emotional maturity,
achievement in other subjects and attendance shall be considered.
       Students considered for retention in grades K-6 for the first time shall be reviewed by the
Teacher Assistance Team (TAT). These results are to be used as supportive information and not
be the sole instrument to determine retention. For those students whose educational performance
                                                  26
is not commensurate with their peers and are suspected of having exceptionality, a written referral
to the TAT shall be made.
        Should a student be considered for a second elementary retention that student will
automatically be referred to the TAT for consideration for evaluation. This is to be done by the first
week in April of each school year.
When a student is experiencing academic difficulty, the parent(s) shall be notified as soon as
possible. Should a student be seriously considered for retention, the parent(s) shall be
notified by March 1, unless there are reviewed, mitigating circumstances. A conference should
be scheduled with the parent(s) to discuss the probability of retention as well as to counsel
with the parent(s) on how to deal with the retention should it occur. Written permission from
the parents for retention is not required, but parent(s) must be notified of the specific reasons
for retention.
        Grades on the report cards are to reflect evidence of the student’s inclination for
promotion and/or retention. The final decision in regard to promotion and/or retention rests
with the individual classroom teacher(s) and building principal. Additional professional staff
members may be consulted for input. Should there be an impasse at the school level; the final
decision will be made by the appropriate administrator.
        A student who has failed for two years in the same grade and who has been tested with
the results not indicating the need for special education services, is then considered for
promotion or retention by a committee made up of the principal, counselor, and all teachers
who have had classroom contact with the student. All academic, emotional, and social areas
as well as their chronological age should be considered by this committee in regard to the
student’s promotion or retention.

Physical Education: Everyone will participate in physical education and playground activities
unless they are excused for health reasons. State Law requires that student cannot be
excused from Physical Education for more than one day due to illness or injury without
obtaining a doctor’s excuse. These excuses are to be given to the P.E. teacher.

Reporting Accidents: If at any time during the school day, or at school functions within the
building, or the school grounds, if anyone is injured in an accident, please report this to the
office as soon as possible; always on the day of the accident.

School Board Meetings: The Hendricks School Board meets on the 3rd Tuesday of each
month in the Media Center. Agendas are posted a minimum of three days prior to the
meetings. Occasionally, special board meetings are held; the agendas for these meetings are
also posted a minimum of three days prior to the meetings. Community attendance is
encouraged at these meetings.

School Closings There will always be an announcement on the radio and TV when school is
closed, starting late due to weather or emergency conditions and early dismissals.

       KMHL-Marshall               KBRK-Brookings AM 1430 KLOH-Pipestone
       WCCO AM 830- Mpls.          KSFY TV                KELO-TV

School closing decisions are made by the Superintendent of Schools and Head School Bus
Drivers. Such decisions are always made with student safety in mind. Generally the stations
are called by 6:00 AM. A two-hour late start means weather conditions will be reviewed and a
decision will be made to stay either with the late start or dismiss for the entire day. Parents
are advised to listen for last minute changes. Parents have the right to keep their child home
on days with questionable weather. Students will be excused from school that day with a
phone call to the office.
                                                  27
A two-hour late start does not cancel the A. M. Preschool.

Worsening weather conditions may force the early closing of schools. If this should happen,
the above radio stations will carry this information. On such a day, our phone lines become
jammed. Do not plan for your child to contact you by phone. Be prepared in advance. If there
is any concern whether or not a child should attend school because of weather conditions or
leave school prior to dismissal for the same reason, parents will be responsible for making that
decision. We ask that you please discuss with your child where he/she is to go if we
dismiss early and please share the plans with your child’s teacher prior to an early
dismissal, if possible.

In addition to the above we would like to add that if school closes early due to inclement
weather, there would be NO AFTER SCHOOL ACTIVITIES at the Elementary School.

School Reach:
                                 Hendricks Public Elementary School

To whom it may concern,

In our effort to improve communication, Hendricks Public School is implementing a telephone broadcast system
that will enable personnel to notify all households and individuals by phone within minutes of an emergency or
unplanned event. The service may also be used from time-to-time to communicate general announcements or
reminders. This service is provided by SchoolReach, a company specializing in effective communications.

When used, the service will call all phone numbers in our selected contact lists and will deliver a recorded
message from an administrator. The service will deliver the message to both live answer and answering
machines. No answers (phones ringing over 40 sec.) and busies will be automatically retried twice in fifteen minute
intervals after the initial call.

PLEASE NOTE THE FOLLOWING:

1) This requires NO registration by the recipient on the SchoolReach website.

2) All information and contact numbers are strictly secure and confidential and are only used for the purposes
described herein.

Here is some specific information you should know:

   Caller ID:                   The Call ID will display a designated school line, which is the main
                                 number that will be used for Hendricks Public School HI.

   Live Answers:                There is a short pause at the beginning of the message,
                                 usually a few seconds. Answer your phone as you normally would; “hello” and
                                 hold for the message to begin. Multiple “hellos” will delay the message. Inform all
                                 family members who may answer your phone of this process.

   Answering Machines:          The system will detect that your machine has answered and will play
                                 the recording to your machine. The phone will ring for up to 40 seconds. Make
                                 sure that your machine answers after four rings or you may miss the message.

   Message Repeat:              At the end of the message you will be prompted to ‘press any key’ to hear the
                                 message again. This is very helpful when someone other than the intended
                                 recipient initially answers, allowing the recipient to then ‘repeat’ the message in its
                                 entirety.

If you have any questions, please contact Mrs. Jensen at the school.


                                                         28
SchoolReach, the service provider, uses the best available technology in the industry to detect the difference
between human answer and machine or voicemail answer.

Here’s how detection works:

        1. The system detects and measures the voice energy when the phone is answered.
        2. The system measures this energy in combination with the background noise and line impairments.
        3. If the system determines that it is a “live” answer, it will immediately start playing the message.
        4. If the system determines that it is a machine, it will wait for three full seconds of silence before playing
           the message with a maximum wait time of twenty seconds.
        5. If the system cannot make a determination, it will default to answering machine thus requiring several
           seconds of silence for the message to play. In this case, you may hear a prompt to “press any key to
           hear the message immediately.”

Some reasons for false detection:

        1.   Loud background noise; television, radio, general noisy environment.
        2.   A cordless phone that has static or other foreign noise.
        3.   Not saying “hello” or repeatedly saying “hello”.
        4.   Cellular phones which, when called, have the ‘ringback tones’ music option.
        5.   Answering machine/voice mail greetings which are too long or have long pauses in speech.

What can be done to remedy this?

        1. Do not say “hello” more than once. If the system detected your answer incorrectly, all noise will reset
           the three-second counter.
        2. If, after you answer, the message does not immediately play, cover the mouthpiece of the phone to
           cutout all background noise. The message should begin after three seconds.

Please make every effort to provide Hendricks Public School with current and accurate phone information any time
there is a change to ensure that you do not miss important information.

In an important effort to make the best and most accurate use of the SchoolReach system, we are asking that you
fill out the following form with the requested necessary information. After filling this out for each recipient, please
double check for accuracy and return it to us promptly.


Thank You,
Mrs. Jensen

School Dance Rules:
  1. All dances are to be scheduled through the administration.
  2. All of the basic rules of conduct also apply to dances.
  3. Once a student leaves the building he/she will not be allowed to re-enter.
  4. Two faculty members and two couples of parents must be at every school dance.

Selling Merchandise: No student will be allowed to sell merchandise as a school project
unless such a project has been authorized through the administration.

Student Council: The Student Council is made up of one student representative from each
class (5-12). It meets periodically to discuss recommendations concerning school problems
and activities. If you have suggestions concerning the improvement of our school, you can tell
them to your class representative, who will bring them up at a council meeting.

Student Records: Student records are kept on each child for his/her entire school career.
The cumulative folder contains such items as copies of report cards, state test results,
attendance records, etc. These records are confidential, and access to them is limited to
school employees and parents. Parent permission must be obtained to release these records
to another party.
                                             29
                         School and Playground Conduct

1. Students shall walk at all times in the school building
   and adjacent areas.
2. Students shall refrain from speaking loudly in the
   hallways.
3. Students shall speak in proper and acceptable
   language. No profane or obscene language will be
   tolerated.
4. Students shall obey all school personnel such as
   teachers, aides, cooks and custodians while on the
   playground, in the halls, in the lunchroom and in the classrooms or at any
   assigned area.
5. Students are not allowed to play rough body contact games. Tag games are
   permissible but this does not permit hitting and pushing. No tackling or tackle
                               football.
                           6. Students are to remain in the playground area. The
                               boundaries for the playground are designated by the
                               Principal on the first day of school.
                           7. Students are not to cross the road or enter the
                               building unless the playground supervisor gives
                               permission.
8. No hard baseballs, roller blades, bicycles or scooters on the playground.
9. Sleds are allowed; however, need to be in safe condition.
10. No throwing snowballs.
11. Guns, knives, toy or real, shall not be allowed on school premises.
12. Students shall refrain from standing in the swings, or standing and lying on
   top of the climbing bars or playground equipment.
                          13. No climbing on the outside of the slides.
                          14. Depending on the weather and condition of the
                              playground, all students need to be properly dressed
                              and encouraged to be out for free play. All students
                              need coats, hats, boots, mittens, and snow pants for
                              outside play in the winter.
                          15. Students must stop playing and line up
                              immediately when the signal is given.

                                    STUDENTS SERVICES
     ELL: English Language Learners is program that instructs students of limited English
      proficiency in the four language skill areas of listening, speaking, reading and writing.

     DAPE and Occupational Therapist: DAPE – Developmental Adapted Physical
      Education (DAPE) is provided to students who qualify as determined through gross
      motor assessments and meet eligibility criteria as determined through Special
                                             30
       Education Assessment. Occupational Therapy (OT) is provided to students who qualify
       as determined through fine motor assessments.

      Guidance Counselor/Social Worker: Hendricks Public School students have access
       to a social worker/counselor. Students may meet with a counselor/social worker in a
       group or individual setting through parent approval and/or teacher referral.

      Section 504 –Rehabilitation Act: Section 504 of the Rehabilitation Act of 1973
       prohibits discrimination against persons with a handicap in any program receiving
       federal financial assistance. The Act defines a person with a handicap as anyone who:
       1. has a mental or physical impairment, which substantially limits one or more major life
       activities. (Major life activities include such things as caring for ones self, performing
       manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.) It
       is the policy of the Hendricks School District not to discriminate on the basis of
       handicap in admission or access to, or treatment or employment in, its programs and
       activities. The district will identify, evaluate, and provide an appropriate public education
       to students who have a handicapped condition within the meaning of Section 504 of the
       Rehabilitation Act of 1973. Copies of Section 504 of the Rehabilitation Act of 1973 are
       available in the office.

      Speech: A speech clinician is employed by the school district to work with all the
       children in the district who need speech therapy as determined through a Formal
       Speech Assessment.

      Special Education: Extra help is provided to qualifying students through abroad range
       of programs such as Early Childhood Special Education, Speech, Specific Learning
       Disabilities, Emotional/ Behavioral/Severely Impaired, Physical Therapy, Occupational
       Therapy, Developmental Adaptive Physical Education and Hearing Impaired. A school
       psychologist is employed to provide diagnostic assessment of students and make
       recommendations to teachers and parents relative to specific needs of students. You
       may contact your building special education staff for additional information.

      Student/Parent Rights under FERPA: Hendricks Public School recognizes its
       responsibility in regard to collection, maintenance and dissemination of public records
       and the protection of the privacy rights of students as provided in federal law and state
       statutes. The procedures and policies adopted by ISD#403 regarding the protection and
       privacy of parents and students are pursuant to the requirements of 20 U.S.C. & 1232g,
       et seq.,(Family Educational Rights and Privacy Act), 34 C.F.R. Part 99 and consistent
       with the requirements of the Minnesota Government Data Practices Act. Minn. Stat. Ch.
       13 and Minn. Rules. Pts. 1205.0100 to 1205.2000. (Policy #515) A complete copy of
       the Student/Parents Rights under FERPA policy is on file in the office or district office.

      Supplemental Reading Program: Supplemental help is provided to qualifying students
       needing extra help in reading. Students are given out of class instruction that addresses
       their needs in addition to the classroom language arts language.

Student Sex Discrimination: Students are protected from discrimination on the basis of sex
pursuant to Title IX of the Education Amendments of 1972an Minnesota Human Rights Act.
Hendricks Public Schools provides equal educational for all students, and does not unlawfully
discriminate on the basis of sex (Policy#522).


                                                31
                                         Study Island/Reading Eggs: Students in grades
                                         2nd grade – 6th grade have home and school access
                                         to Study Island. Reading Eggs is offered to
                                                                     st
                                         students in grades Pre-K-1 grade. Study Island is
a Web-based instruction, practice, assessment and reporting built from our Minnesota state‘s
standards.
               Reading Eggs is a comprehensive, online supplemental literacy program for
               early learners ages 4 through 8. Grounded in extensive educational research,
               Reading Eggs builds on and reinforces the five key reading pillars: phonemic
               awareness, phonics, fluency, vocabulary and comprehension.
Both programs can be accessed by your child’s provided username and password. If you
need a reminder of the codes, please contact the principal or your child’s teacher.

Tardiness: Any student who is not in his/her assigned classroom by 8:00 am will be
considered tardy unless school personnel have received proper notification. Tardiness is
included on our attendance records.

Telephone Calls: It is necessary to limit the use of the telephone. We request that students
not be called during the school day unless it is an emergency. Students may return messages
and call back between classes or at noon.

TERRANOVA 3rd Edition: TerraNova, Third Edition Multiple Assessments measures
important higher-order thinking skills as well as basic and applied skills. These assessments
generate norm-referenced achievement scores, criterion-referenced objective mastery scores,
and performance-level information. This evaluation is administered to grades K-2 in the
spring.

Textbooks: Each student will be responsible for the textbook issued to him/her at the
beginning of the year. The teacher will make a list of the condition of the books when they are
issued. Fines may be issued depending on the condition of the book when returned to the
school.

Transfer: Please inform the school if you move from the district. Parents must sign a request
for release of their child's records when they enroll in their child's new school.

Tobacco Products, Alcohol or Controlled Substances: Students are prohibited from using,
possessing, selling, or distributing tobacco products, alcoholic beverages, or other controlled
substance on school grounds, in school vehicles, or at school sponsored activities.
Disciplinary action may include, but is not limited to: students and/or parent conference; loss of
school privileges; suspension from school and/or school activities; referral to in-school support
services; referral to police or other law enforcement for criminal action; referral to court
services; and expulsion from school.

Copies of the District Policies #417 and #418 regarding Chemical Health and Violations are
available in district office.

Tobacco-Free Environment: The purpose of this policy is to maintain a learning environment
that is tobacco free. It shall be a violation of this policy foray student, teacher, administrator,
and other school personnel of the school district or person to use tobacco or tobacco-related
devices in a public school. This prohibition extends to all facilities, whether owned, rented, or

                                                32
leased and all vehicles the school district owns leases, rents, contracts for, or controls. This
prohibition includes all school district property and all off-site school district sponsored events.
The school district will act to enforce this policy and to discipline or take appropriate action
against any student, teacher, administrator, school personnel, or person who is found to have
violated this policy. Copy of the District Policy#419 regarding the Smoke/Tobacco Free
Environment policy is available in the district office.

Visitation: Parents are always welcome and are urged to visit classes. You are encouraged
to leave younger children at home when visiting a classroom. Occasionally we have requests
by students to bring other children as guests to the school during the day. We are NOT open
to this type of request.

Weapons Policy / Dangerous Articles The School Board of District #402 recognizes the
need to provide safe and secure schools throughout the District. Safe and secure schools lead
to effective teaching/learning situations. This, in turn, leads to positive outcomes. The
presence of weapons creates an environment that is opposed to what the schools believe.
Students are forbidden to knowingly possess any instrument or object on school property, at
school sanctioned activities, on parking lots and areas regularly utilized for parking during
school functions, or when students are being transported in vehicles dispatched by the district
or in transportation provided for educational trips, that is a weapon as hereinafter defined. A
weapon is defined as any object which may be used to intimidate or inflict bodily harm which
has no school related purpose and which shall include but not be limited to the following items:
knives of all types, guns, toy guns, lead pipes, chains, numchucks, throwing stars, metal
knuckles, blackjacks, unauthorized tools, explosives, laser pointers, or other chemicals.

A weapon means: any firearm, whether loaded or unloaded, any device or instrument
designed to be capable of threatening or producing great bodily harm or death. (See District
Policy for more examples.) Possession: shall mean having a weapon on one’s person or in the
area subject to one’s control on school property or at a school activity.

      Consequences confiscation of the weapon, notification of the police department,
       immediate suspension for five (5) days, is commendation that the student be expelled
       from school. Dangerous or illegal articles will be confiscated and turned over to the
       proper authorities. Such articles will NOT be returned to the student. (Policy #501)

A student violating these rules shall be subject to suspension and expulsion. Such penalty
shall be administrated in accordance with school policy. Upon showing that the student has
violated this weapon policy, the student shall be expelled for the remainder of the school year
and all grades and credits for classes not completed as of the time of the violation of this
policy shall be forfeited.

Upon being informed that a student has violated this policy, the school administrator or other
acting building administrator may take the following action:
              1. Notify the sheriff's department;
              2. Confiscate the weapon;
              3. Impose an initial suspension;
              4. Commence the procedure for expulsion;

      The building administrators shall have the right to use their discretion in the
implementation of this policy.


                                                 33
Website: Hendricks Public School has a website with a lot of information about the school
and upcoming events. The website address is http://hendrickspublicschools.org/. At this site,
you will find the master schedule for the building, student handbook, supply list, school year
calendar, monthly calendars, hotline, and much more.




                                              34
                                   ANNUAL NOTICE AND
                          INFORMATION REGARDING SECTION 504
                            OF THE REHABILITATION ACT OF 1973


Section 504 is an Act, which prohibits discrimination against persons with a disability in any
program with federal financial assistance. The act defines a person with a disability as anyone
whom:
        1. Has a physical or mental impairment which substantially limits one or more major life
activities including activities such as caring for one's self, performing manual tasks, seeing,
hearing, speaking, breathing, learning, and working.

       2. Has a record of such an impairment; or

       3. Is regarded as having such impairment.
        (34 Code of Federal Regulations part 104.3)

In order to fulfill its obligations under Section 504, the Hendricks Public School recognizes a
responsibility to avoid discrimination in polices and practices regarding its personnel and
learners. No discrimination against any person with a disability will knowingly be permitted in
any program and practices in the school system.

The school districts have specific responsibilities under the Act, which include the
responsibility to identify, evaluate, and if the child is determined to be eligible under Section
504, provide access to appropriate education services.

If the parent or guardian disagrees with the determination made by the professional staff of the
school district, he/she has a right to a hearing with an impartial hearing officer.

The Family Educational Rights and Privacy Act (FERPA) also specifies rights related to
educational records. The Act gives the parent or guardian the right to: 1) inspect and review
his/her child's educational records; 2) make copies of these records; 3) receive a list of all
individuals having access to those records; 4) and for an explanation of any item in the
records; 5) ask or an amendment to any report on the grounds that it is inaccurate, misleading,
or violates the child's rights; and 6) a hearing on the issue if the school refuses to make the
amendment.

If there are any questions, please feel free to contact Mr. Bruce Houck, the 504 Coordinator,
for the elementary building at 507-275-3115.




                                                 35
                                    *** ATTENTION ***

                   DISTRICT #402 POLICIES AGAINST RELIGIOUS,
                 RACIAL AND SEXUAL HARASSMENT AND VIOLENCE

1. Everyone at District 402 has a right to feel respected and safe. Consequently, we want
   you to know about our policy to prevent religious, racial, or sexual harassment and
   violence of any kind.

2. A harasser may be a student or an adult. Harassment may include the following when
   related to religion, race, sex or gender:

       a.   name calling, jokes, or rumors;
       b.   pulling on clothing;
       c.   graffiti;
       d.   notes or cartoons;
       e.   unwelcome touching of a person or clothing;
       f.   offensive or graphic posters or book cover; or
       g.   any words or actions that make you feel uncomfortable, embarrass you, hurt
            your feelings or make you feel bad.

3. If any words or actions make you feel uncomfortable or fearful, you need to tell a
   teacher, the building administrator or the Human Rights Officer, Mr. Bruce Houck.

4. You may also make a written report. It should be given to a teacher, counselor, the
   principal or the Human Rights Officer.

5. Your right to privacy will be respected as much as possible.

6. We take seriously all reports of religious, racial, or sexual harassment or violence and
   will take all appropriate actions based on your report.

7. The School District will also take action if anyone tries to intimidate you or take action to
   harm you.

8. This is a summary of the School District policy against religious, racial and sexual
   harassment and violence. Complete policies are available in the Superintendents office
   upon request.

  RELIGIOUS, RACIAL AND SEXUAL HARASSMENT AND VIOLENCE ARE AGAINST
                               THE LAW.

                         DISCRIMINATION IS AGAINST THE LAW.

CONTACT:             Mr. Bruce Houck
                  HUMAN RIGHTS OFFICER

                         (507) 275-3115
                             PHONE




                                             36
                      INDEPENDENT SCHOOL DISTRICTS NO. 402
      RELIGIOUS, RACIAL OR SEXUAL HARASSMENT AND VIOLENCE REPORT FORM

            General Statement of Policy Prohibiting Religious, Racial or Sexual Harassment

Independent School Districts No. 402 and 403 maintains a firm policy prohibiting forms of
discrimination. Religious, racial or sexual harassment or violence against students or employee is
discrimination. All persons are to be treated with respect and dignity. Sexual violence advances or other
forms of religious, racial, or sexual harassment by any pupil, teacher, administrator or other school
personnel, which create an intimidating, hostile or offensive environment, will not be tolerated under any
circumstances.

Complainant_________________________________

Home Address________________________________________________________________________

Work Address________________________________________________________________________

Home Phone ______________________________Work Phone_________________________________

Date of Alleged Incident(s) ______________________________

Circle as Appropriate         Physical                Sexual         Racial         Religious

Name of person you believe harassed or was violent toward you or another person._________________

If the alleged harassment or violence was toward another person, identify that person._______________
____________________________________________________________________________________

Describe the incident(s) as clearly as possible, including such things as what force, if any, was used: any
verbal statements (i.e. threats, requests, demands, etc.); what, if any, physical contact was involved; etc.
(Attach additional pages if necessary.)_____________________________________________________
____________________________________________________________________________________

Where and when did the incident(s) occur? _________________________________________________

List any witnesses who were present.______________________________________________________

This complaint is fled based on my honest belief that ______________________________ has harassed
or has been violent to me or to another person. I hereby certify that the information I have provided in
this complaint is true, correct and complete to be best of my knowledge and belief.

______________________________                                 ____________________
Complainant Signature                                          Date

______________________________                                 ____________________
Received By                                                     Date




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