500.16F2 STUDENT MEDIATION AGREEMENT
STUDENT MEDIATION AGREEMENT
Student:_____________________________ DOB:____________ Grade: __________
School: ________________________________
DATE OF MEDIATION: __________________________
PARENT CONTRACTED ACTION: __________________________
1. Parent will have the child attend all classes everyday during the school year, unless properly excused with a physician’s note, or by the school administration. This includes:
a. The physician’s note must include the exact nature of the illness and the exact date and times that the student will need to miss school. Any follow up appointments should be noted, as well as limitation of involvement/activity during the school day. Child must be seen in the office by a Doctor/LMHP/Physician Assistant.
b. The parent will sign a release of information to the Doctor/MHP/Physician Assistant/Nurse for the school if requested.
c. If the student is sick or feeling sick, and a physician has not been consulted to excuse the student, the student is expected to go to school and consult the school health personnel. This person will make the determination as to whether the student should be excused from school for that specific day.
d. All doctor’s notes must be turned in to the school no later than 3 days after the missed class time.
Parent will cause child to attend school on time with no unexcused tardies. Tardies can be counted as truant and may result in legal action being taken.
Parent agrees to allow the Mills County Attorney’s office access to attendance/ discipline records of the child. This information may be accessed via written or electronic access.
CHILD EXPECTED BEHAVIOR:
1. To use appropriate and acceptable behavior with the school staff and other students. This behavior is outlined in the GCSD Code of Conduct and each school's handbook.
2. To ask for make-up work when absent, to complete that work, and turn it into the individual teacher in a timely manner.
3. To take the necessary materials and completed assignments to each class, each day.
4. To be in bed and wake up by a reasonable time on school days.
5. To be at the bus stop on time, if applicable.
The following signatures indicate an agreement to the Mediation Contract and of the above expectations.
Student ________________________________________ Date:__________________
Parent(s) ____________________________ SS#________________ DOB:_________
School Admin ______________________________________ Date:_______________
Mediator___________________________________________ Date:_______________
*Adopted: 11/14/16
*Reviewed: 04/12/21
*Reviewed: 07/17/23
