What is Domestic Violence?
Teen Dating Violence
Model Stay-Away Contract and Safety Plan
ABC SCHOOL DISTRICT STAY AWAY CONTRACT/ SCHOOL SAFETY PLAN
Home Room____________________ Bus Route/Walk/Park___________________________
A complaint of ____________________________________ _________________________was made against you by ___________________________________ on (date) .
This behavior is a violation of our school policy/code of conduct. As a result,
the following conditions will be instituted from (date) through (date) . Violation
of this stay away contract will result in
suspension and/or expulsion from ABC school district.
Arrival/Departure Schedule
Time__________________________________________________
Entrance_______________________________________________
Bus/Walking Route/Parking__________________________________________
Schedule Changes:
Period 1______________Passing Time & Route______________
Period 2______________Passing Time & Route______________
Period 3______________Passing Time & Route______________
Period 4______________Passing Time & Route______________
Lunch Period__________Passing Time & Route______________
Period 5______________Passing Time & Route______________
Period 6______________Passing Time & Route______________
Period 7______________Passing Time & Route______________
Extracurricular Activities________________________________
Student__________________________________Date____________
Parent/Guardian__________________________Date____________
Administrator____________________________Date____________
YOU are responsible for following the conditions of the stay
away contract.
Violations of the contract will result in further disciplinary action by the
ABC
School Administration.
ABC SCHOOL DISTRICT STAY AWAY CONTRACT/ SCHOOL SAFETY PLAN
Name___________________________________________________
A stay away contract has been instituted on your behalf. The contract was
initiated on (date)
and will expire on (date) .
__________________________ is responsible for following the conditions of the contract. Any violation will result in further disciplinary action by the ABC School Administration. Please find a copy of ________________ schedule and passing times and routes below.
Arrival/Departure Schedule
Time__________________________________________________
Entrance_______________________________________________
Bus/Walking Route/Parking______________________________
Schedule Changes:
Period 1_____________Passing Time & Route_______________
Period 2_____________Passing Time & Route_______________
Period 3_____________Passing Time & Route_______________
Period 4_____________Passing Time & Route_______________
Lunch Period_________Passing Time & Route_______________
Period 5_____________Passing Time & Route_______________
Period 6_____________Passing Time & Route_______________
Period 7_____________Passing Time & Route_______________
Extracurricular Activities______________________________________________
______________________________________________________
Support Network
The following have been identified as a support network for you.
Staff__________________________________________________
Peers__________________________________________________
Student_________________________________Date___________
Administrator____________________________Date__________
ABC SCHOOL DISTRICT STAY AWAY CONTRACT AGREEMENT
I, __________________________________ agree to abide by the rules as outlined in the attached stay away contract. In addition, I will not attempt any contact with ______________________________ while on ABC School grounds, or at any school-sponsored activity. No contact includes notes or messages (including e-mail) through friends, relatives or school staff.
Any violation of this contract will result in further disciplinary action by ABC School administration including suspension and/or expulsion. If an existing court restraining order is in place, ABC School will immediately notify the police of any violation of the restraining order, as mandated by law.
I have read and understand this agreement.
Student____________________________________Date________
Parent/Guardian____________________________Date________
Administrator_______________________________Date________
