BASIC DISCIPLINE 101
As you the student have chosen to disrupt the education flow in my class, the following form has been created. This is direct communication and/or contact, via the instructor to the student, that the following behavior(s) will no longer be tolerated. This is the first step, in a three-step process, which will lead to further disciplinary actions if the behavior creating this situation is not corrected immediately. This is not open for discussion and/or debate during class time. You, the student, are to print your name in the assigned spot and date this form. If you have any questions about this situation, the instructor will be available before and/or after school, on your time, for consultation. You will sign this form at the bottom and return it to the instructor by the end of the class period it was received in.
STUDENT’S NAME:_____________________________________________________________
DATE:_____________________________________
A mark on the appropriate line indicates that your level of performance is unacceptable and needs to be corrected.
1) ____ You are tardy/late to class.
2) ____ You are talking without permission too often. You will raise your hand and be
called on before you speak.
3) ____ You are talking to your neighbor and/or distracting him or her from my
information about the lesson.
4) ____ You are not prepared for class: no pencil, no paper, no notebook, and/or no
other special needs assigned for the class and/or shop environment.
5) ____ You did not follow the School Board policies set by the Cameron R-I School
District.
6) ____ You have demonstrated disruptive behavior that is taking away from productive
class time: excessive and/or loud talking, excessive movement in and around the
classroom and/or shop, reading/writing/and or passing notes that do not pertain to class, acting silly, ect…
7) ____ You, the student, refused to do assigned class work as allocated by the instructor
in a reasonable amount of given time.
8) ____ You have created an unsafe environment for us to work in.
9) ____ You are using a cell phone, ipod, or other electronical device during class time.
10) ____ Your use and/or abuse of school property is unacceptable: leaning back in your
chairs, defacing school property, unsafe/misuse of shop tools, etc.
Student’s signature:______________________________________
Failure to conform to this form automatically takes you to step three and sends you to the office for further disciplinary action. No debate and/or no discussion.
____ Student refused to sign and return said form.
