Mecklenburg County Public Schools Student Discipline Referral
Student Name
Date of Birth
Age
School
Grade
Parent
Home Phone Number
Alternate Phone Number
Address
Special Education Services
NO
YES
Disability
Reason for Referral
Recommended Action
Long Term Suspension
364 Day Suspension
Expulsion
Other
Summary of Incident
The following documents have been submitted to the central office:
Student Attendance Detail Report, Student Report Card, Student Discipline Detail Report, Discipline Slip
Date Sent
Date
Administrator
Indicates Response Required