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Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail

Are you filing this form on behalf of a specific child?

YesNo

If so, please provide the name of the child.

First NameLast Name

Name of School

School's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

E-mail

Please provide an explanation of what you believe to be the curriculum deficiency. Attach any documentation that will substantiate your allegations (upload option at end of form).*

Please provide an explanation as to how the school entity could remedy what you believe to be a curriculum deficiency.

Did you file a complaint with the School? If so, please provide the name(s) and title(s) of school official(s) whom you contacted, a brief summary of the outcome you sought and steps taken by the school to resolve your complaint.

Did you file a complaint via other procedures within the Pennsylvania Department of Education (e.g., special education, gifted education, early intervention, educator misconduct, higher education, private schools, enrollment, homeless)? If so, identify which one(s).

Have you contacted another agency or organization about this matter? If so, please provide the agency’s and/or the organization’s name.

Are you represented by an attorney concerning this matter? If so, please provide the attorney’s name.

Upload any supporting documentation for this complaint

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Pursuant to 18 Pa. C.S. § 4904(a), and under penalty of perjury, I declare the foregoing to be true and correct to the best of my knowledge. I also grant PDE permission to release my name and allegation details to the school entity.

Signature of Complainant*

Use your mouse to make a signature on the line. Your signature is required by the PA Dept. of Education.

Date*

MonthDayYear

The individual filing the form with PDE must attest that the following is true:

The person has signed the form attesting to the truth and accuracy of the allegations.The person has signed the form to authorize the disclosure of his/her name and allegations.The person has submitted evidence, if the person has any, to support the allegations against the school entity. (Please do not submit original documents, as they may not be returned.)The person recognizes that PDE will not process an anonymous form.By signing the form, the person acknowledges that PDE may share the complainant’s name and the information provided by the complainant with the school entity in order to investigate the allegations.

I give permission for Public Interest Law Center and its partners to access this information for use in potential group complaints. My information will remain confidential and will not be used without my permission.

I agree

Click Print Form before submitting to keep a copy of this complaint for yourself. A copy will also be emailed if you provide an e-mail address above.

Year

School's Contact Information

Statement of Alleged Curriculum Deficiencies