102.E2 - Grievance Form for Complaints of Discrimination or Non-Compliance with Federal or State Regulations Requiring Nondiscrimination

I, ___________________________________________, am filing this grievance because
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(Attach additional sheets if necessary)

Describe incident or occurrence as accurately as possible:

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Signature ______________________________________________________________________

Address _______________________________________________________________________

Phone Number_________________________________________________________________

If Student, Name__________________________________Grade Level__________________

Attendance Center __________________________________________________________