The River Valley School District values and respects the human diversity of members of the school community. In order to maintain a school environment which encourages optimum human growth and development for students and others acting in the District's behalf, it is the policy of the Board to maintain and ensure a learning and working environment free of any form of student harassment or intimidation.
Complainant: __________________________________________________________________
Home Address: ____________________________________________________________
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Work Address: ____________________________________________________________
Home Phone: ____________________________ Work Phone: __________________
Date of alleged incident(s): ______________________________________________________
Describe the incident(s) as clearly as possible:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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This complaint is filed based on my honest belief that ______________________________
has personally harassed me. I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.
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Complainant Signature Date
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Received by Date
APPROVED: November 11, 1999
12/21/2004 pw