GRIP Registration Form

GRIP will cover drug & violence related topics (Grades 6-12).

Dates for GRIPrequired

Administrator

Namerequired

Administrator's First Name:

Administrator's Last Name:

Administrator's Email Addressrequired

Administrator's Phone Number

Parents

Parent's Email Addressrequired

Parent's Phone Number

Student

Student Id:

Student's School Namerequired

Namerequired

Student's First Name

Student's Middle Initial (optional)

Student's Last Name

Special Needs?

Student has special needs

Student's Age:required

Suspension Days:

In Schoolrequired

Out of Schoolrequired

Total:required

Languages Spokenrequired

English

Spanish

Other

Previously Attended?

Student has previoulsy attended and completed this program.

Referral Categories

Please state the categories for referral as stated in the Rights and Responsibilities Handbook. Provide a BRIEF description of the offense.

Referral Reason

Please state a brief reason(s) for referral IF NOT LISTED in the Rights and Responsibilities Handbook.

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