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Rebound Referral Form 2019 -2020
Student First Name *
Your answer
Student Last Name *
Your answer
Current Grade *
School *
If Other School Name
Your answer
Reason for Suspension *
Your answer
Have parents been notified about suspension and referral to Rebound? *
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number (mobile is best) *
Your answer
Number of Days Suspended *
First Day of Suspension *
MM
/
DD
/
YYYY
Last Day of Suspension *
MM
/
DD
/
YYYY
Is the student eligible for DPS transportation (available to any student who requests transport, unless principal sees a safety issue with bus) *
(For Conflict Mediation Purposes) Name of other students involved who will also be referred to Rebound
Your answer
Last Name of Person Completing referral *
Your answer
Please list name of referring agency if outside DPS
Your answer
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