CCJHS Discipline Form (Consequences are below)

Student’s Name:__________________________

Date:  ______________  Class Period:________

Teacher:___________          Subject: ________

                                       INFRACTION

___Tardy                                  ___Destroying School Property

___Excessive Talking                   ___Unacceptable Language

___Annoying to classmates           ___Fighting

___Rude/discourteous                

___Refusing to Work                 ___Disruptive

___Unprepared                         ___Other

CONSEQUENCES

6 checks--Loses reward activity

8 checks--Thursday School/ISS

10 checks--ISS

13 checks--Thursday School

15 checks--ISS

Teacher Comments:________________________________________

_________________________________________________

Student Signature:_________________________________

Parent Signature:__________________________________