Dansville Student Concern Form
Please complete the information below if you have a concern for a student's well being.
Sign in to Google to save your progress. Learn more
This form will only be seen on School Days from 7:30 AM – 3:00 PM.  If it is after 3:00, a weekend or vacation day, please call 911 with your concern and follow up with your counselor during the next school day. *
I am concerned about: (First & Last Name) *
I am concerned about the student for the following issues (please check all that apply) *
Additional details explaining the reason that I am concerned (please be as specific as possible):
I would like to speak with an adult about this as soon as possible during the next school day *
I understand that if I am completing this form after school hours and I believe that the individual is in immediate danger, I will call 911 right away. *
My name is (will be kept confidential)
For safety reasons, in order to make sure that someone addressed your concern right away, this form will be submitted to the High School Counselors for their review and action
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dansville Central Schools. Report Abuse