Student Services Help Request
After completing this form, please ask Mrs. Pickett (secretary) for a pass back to class. A member of Student Services will speak with you regarding your issue within 24 hours.
Is this Urgent? (Danger to your self? Danger to others?) *
What is your first name? *
Your answer
What is your last name? *
Your answer
Today's Date: *
MM
/
DD
/
YYYY
Date of Incident: *
MM
/
DD
/
YYYY
Location of Incident: *
Your answer
My grade/team is: *
Check the issue (s) or problem (s) you are currently experiencing. *
Required
Identify the person with whom you are having an issue. *
Your answer
How many times has this happened to you? *
Explain the problem or issue that you are experiencing. *
Your answer
What steps have you taken to try and solve the problem/issue? *
Required
Can you name any witnesses who saw or heard the incident you are reporting?
Your answer
When is your lunch period? *
Submit
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This form was created inside of Troy Community Consolidated School District 30-C.