Cell Phone and Electronic Device Violation Form 
Please complete this form when a student is turning in a cell phone or electronic device to the office. 

  • Violation 1 Staff receives the device and places it in a safe location in the classroom for return to the student after the class period. Staff records the violation in a Google Form.


  • Violation 2 Staff receives the device and takes it to the office where the student can pick it up after school.  The teacher records the violation in a Google Form. The teacher contacts the family with a reminder of our policy.


  • Violation 3 Staff receives the device and takes it to the office where a family member must pick it up. The teacher records the violation in a Google Form. The administration contacts the family. The family receives a copy of the policy and signs the document.


  • Violation 4 The student must drop the device off at the office in the morning before 8:14 AM and pick it up at the end of school for the remainder of the quarter or semester, as deemed appropriate by the administration.
Email *
Date *
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YYYY
Student's First Name *
Student's Last Name *
Teacher's Name *
Class Period *
Who in the office did you give the device to? *
Type of Device *
Comments
A copy of your responses will be emailed to .
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