This is a form that is in your hands due to a poor choice you have made. Please realize
that everyone makes poor choices, and it is important to learn from them and understand
why it is inappropriate. During your time, fill this form out completely to reflect and learn
about how your choice has affected you and others around you. Then, turn it into Miss
Mitchell for a meeting.
Describe the situation you were in and what your poor choice was.
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Explain why you made this poor choice.
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How do you think you could have handled this situation differently?
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Was anyone hurt or disrespected by your poor choice? If so, explain what will
you need to do in order to make things right.
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Is there anything your teacher can do to help you in preventing this behavior
from happening again?
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Student Signature ______________________________ Date _______________________
Teacher Signature ______________________________