I am concerned about the student for the following issues (please check all that apply) *
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Additional details explaining the reason that I am concerned (please be as specific as possible):
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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)
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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
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This form was created inside of Dansville Central Schools.