Caesar Rodney School District Title VI Compliant Form
Please Fill Out
Name of Complainant
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Who do you feel is the victim of discrimination?
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Attending? *
Please Select
Frear
MECC
Welch
Magnolia
Kent ILC
Stokes
Star HIll
Simpson
PMS
Brown
Robinson
Fifier
CRHS
DAFBM
Charlton
District Office
In what way do you feel discrimination occurred? Please provide as much background information as possible about the alleged discriminatory act(s).
*
By whom or by what institution or agency do you believe engaged in discrimination?
*
When did the alleged discrimination occur?
*
Where did the alleged discrimination occur?
*
Who do you believe was harmed as a result of the alleged discrimination?
*
Who can be contacted for further information? (Please identify the name, address and telephone for all witnesses)
*
Signature
Email
example@example.com
Submit
Should be Empty: