Last Name:	First Name:
Student Name (if applicable):	Grade:	Date of Birth:
Street Address:
City:	State:	Zip Code:
Cell Phone:	Alt. Phone:
School/Office of Alleged Violation:

For allegation(s) of noncompliance, please check the program or activity referred to in your complaint, if applicable:

 Adult Education

 American Indian Education
 Child Development Programs
 Migrant Education

 Special Education

 Pupil Fees

 Bilingual Education

 After School Education and Safety
 Consolidated Categorical Aid
 Child Nutrition

 No Child Left Behind Programs
 Every Student Succeeds Act Prog.
 State Preschool

 Local Control Funding Formula

 Agricultural Vocational Education
 Career/Technical Education
 Foster/Homeless Youth

 Regional Occupational Programs
 Tobacco-Use Prevention Education
 Lactating Pupils

 Economic Impact Aid

For allegation(s) of unlawful discrimination, harassment, intimidation or bullying, please check the basis of the unlawful discrimination, harassment, intimidation or bullying described in your complaint, if applicable:

 Age

 Ancestry

 Color

 Ethnic Group

 Identification

 Medical Condition

 Gender / Gender Expressio /

Gender Identity

 Genetic Information
 National Origin
 Race or Ethnicity
 Religion

 Sex (Actual or Perceived)

 Sexual Orientation (Actual or Perceived)

 Based on association with a person or group with one or more of these actual or perceived characteristics

 Marital Status

Please give facts about the complaint. Provide details such as the names of those involved, dates, whether witnesses were present, etc., that may be helpful to the complaint investigator.

Have you discussed your complaint or brought your complaint to any JCS personnel? If you have, to whom did you take the complaint, and what was the result?

Please provide copies of any written documents that may be relevant or supportive of your complaint. I have attached supporting documents.  Yes  No

Signature_________________________________________________________	Date: _________________

Mail complaint and any relevant documents to:

Claire Roush

Director of Operations

P.O. Box 2470

Julian, CA 92036

619-832-1220

croush@jcs-inc.org