School Name

First Name Last Name

Date of Incident

THE SCHOOL DISTRICT OF PALM BEACH COUNTYDEPARTMENT OF SAFE SCHOOLS

School-Based Stay Away Agreement This agreement is to be completed with school administration in a conference with the alleged aggressor and his/her parent or guardian. Student ID #

Date of Parent/Guardian Notification Date of Conference with Parent/Guardian

Description of relationship between the parties

School-Based Stay Away Agreement

Alleged Agreesor's Name I, , agree to:

Stay feet from Student Victim's Name

at all times during the school day or on school district property or at school related functions (i.e., all school buildings, grounds, bus stops, school buses, school vehicles, school contracted vehicles, or any other vehicle approved for school purposes; area of entrance/departure from school grounds, premises or events; and all school sponsored activities, events or trips; and walking routes to or from school for the purposes of attending school or school sponsored functions, events or trips).

Refrain from talking to, emailing, calling, text messaging, sending messages to or in any

other form toStudent Victim's Name

Inform the school administration of changes to my schedule and extra-curricular activities.

PBSD 2507 (Rev. 7/23/2015) Page 1 of 2 COPY- Principal, School Counselor, School Police Officer, Parent

Signature of Student Date

.

Has a court order for protection been issued between the two parties? Yes No

RECORDED COPY- Cum folder

Signature of Parent/Guardian Date

PBSD 2507 (Rev. 7/23/2015) COPY- Principal, School Counselor, School Police Officer, Parent Page 2 of 2

In addition, the following schedule changes are effective immediately if so noted below:

Arrival/Departure:Arrival Time: Entrance:

Bus/Parking:

Departure Time: Exit:

Current Schedule New Schedule

Schedule Changes

Lunch: Locker:

Extracurricular Activities:

Other disciplinary actions taken, if any:

Violations of this agreement and acts of retaliation directly or indirectly toward the victim or the victim's friends or family members will be taken seriously and will result in further disciplinary actions. Your compliance with this School-Based Stay Away Agreement will be monitored by (name and title):

Agreement is valid from

This agreement will be reviewed on

Dateto

Date

Date(s)

Signature of Student Date Signature of Administrator Date

Name Title

Additional Staff to Notify:

Did not attend/parent declined

Parent attended but declined to sign

Parent notified via voicemail, email, or letter but did not attend

RECORDED COPY- Cum folder