STUDENT DISABILITY DISCRIMINATION GRIEVANCE REPORT FORM General Statement of Policy Prohibiting Disability Discrimination


Independent School District No. 4142-07 maintains a firm policy prohibiting all forms of discrimination on the basis of a disability.  All persons are to be treated with respect and dignity. Discrimination on the basis of a disability will not be tolerated under any circumstances.


Home Address:

Work Address:

Home Phone:

Work Phone:



I have been discriminated against based on (choose one or more):


[my disability]   /   [a record of my disability]   /   [being regarded as having a disability]






Date of alleged incident(s):


Name of person you believe discriminated against you or another person:




If the alleged discrimination was toward another person, identify that person:




Describe the incident(s) as clearly as possible, including such things as: any verbal statements;

what, if any, physical contact was involved; etc. (attach additional pages if necessary):                






Location of the incident(s):





List any witnesses that were present:








This  complaint  is  filed  based  on  my  honest  belief  that STRIDE Academy has discriminated against me or another person based on a disability.  I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge and belief.




(Complainant Signature)                                             (Date)



Received by: