Instructions: Fill out the online strike report, get it signed, and Upload the Strike Report to the JCS Staff Portal/Student Information.

If this is the student’s third strike, a Drop/Withdrawal Form and progress report or report card MUST accompany the strike report.

Student Name	JCS Student Number	Grade Level	Date
Teacher of Record (EF/Advisor) Name	Teacher of Record Number	Strike Date
Start End

Reason for Strike Report: ☐ Failure to complete at least 80% of assignments or specialist assignments ☐ ☐	Strike Number: ☐ ☐ 1 (Strike Report will be submitted to Main Office and recorded in this student’s records.) ☐ ☐ 2 (Official Warning Letter will be sent to family regarding this student.) ☐ ☐ 3 A (5) day notice will be given to all parents prior to the (Notice of Withdrawal for this student will be sent to family.)

Strike #	Strike Date	Comment	Action Plan
Strike 1 Date
Strike 2 Date
Strike 3 Date:
☐ EF (we should add teacher/coordinator) recommends that Independent Study is not an appropriate placement for this student in the future. ☐ Student withdrawal is pending review

Invited Meeting Participants	Signatures: (EF/Advisor: initial next to any missing party. EF may note N/A next to “Other.”)
☐	____ EF/Advisor: ________________________________________ Date: ________
☐	____ Parent/Legal Guardian:_______________________________ Date: ________
☐	____ Student:___________________________________________ Date: ________
☐	____ Other School Representative: __________________________ Date: ________
☐	____ Other: _____________________________________________ Date: ________

cc: Principal