Parents/Guardian(s):

Please read, sign, and return to ___________________________ by ___________________

PRICE LABORATORY SCHOOL PLEDGE: I promise to respect everyone at Price Laboratory School, to follow school rules, to value all property, to listen to others, to do my best at learning and to cooperate. I will not hurt others with my words or actions. I want Price Laboratory School to be a safe and happy place for all.

Student Name __________________________________________________________________

Date _________________________ Classroom Teacher __________________________

1. What did I do? (Check all that apply)

_____ I did not show respect to _________________________________.

_____ I did not follow school rules.

_____ I did not respect other's property.

_____ I did not cooperate.

_____ I hurt others with my words.

_____ I hurt others with my actions.

Explain: _______________________________________________________________

_____________________________________________________________

2. What effect did my actions have? _______________________________________________

___________________________________________________________________________

3. What should I do in the future? __________________________________________________

_____________________________________________________________________________

Issued by: ________________________________________

MPLS Position: ______________________________________

Comments: ______________________________________________________________________________

_________________________________________________________________________________________

Student Signature _________________________________

Teacher Signature _________________________________

Parent Signature ___________________________________

Comments: _____________________________________________________________________________

________________________________________________________________________________________

Cc: Classroom Teacher, Administration Office, Guidance Office