Recess Removal Form Student’s Name(s)__________________ Teacher/Class________________ ___________________ Date________________ PART I Description of Incident/Behavior: __________________________________________________________________ _____________ __________________________________________________________________ _____________ Intervention(s) Taken (Check all that apply) Verbal Warning Contacted Parent/Guardian Previously spoke to supervisor about an ongoing issue Other:__________________________________________
Recess Removal Approved:
YES
__________________________ Supervisor’s Signature
NO ______________ Date
Number of Day’s for Approved Recess Removal: _______
PART II To be filled out by teacher after approval: Parent notified of RECESS REMOVAL
YES
NO
DATE/Time of Parent Notification:_______________ Name of Parent/Guardian: _____________________ Comments/Notes:_______________________________________________________________ _____________________________________________________________________________ __________________________________ _____________________________________________________________________________ ____________________
ONCE A PARENT/GUARDIAN IS NOTIFIED OF A STUDENT’S REMOVAL FROM RECESS, THE TEACHER WILL BE NOTIFIED OF THE RECESS REMOVAL DATES. NO STUDENT MAY ATTEND THE SAVE ROOM WITHOUT PROPER PARENTAL NOTIFICATION. PLEASE SEND THE STUDENT WITH A BOOK TO READ DURING THIS TIME. THANK YOU.