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0521 Appendix

ENFIELD PUBLIC SCHOOLS Enfield , Connecticut

Discrimination Grievance Form

Any student , parent / guardian , employee or employment applicant who feels that he / she has been discriminated against on the basis of race , color , age , religion , national origin , ancestry , sex , sexual orientation , gender identity or expression , marital status , disability or equal access to the Boy Scouts and other designated youth groups may discuss and / or file a grievance with either of the Civil Rights Coordinators of the Enfield Public Schools . Reporting should take place within 40 calendar days of the alleged discrimination . Civil Rights Coordinators :

Name of Presenter / Complainant : ___________________________________________________ Employee ________ Employment Applicant _______ Student ______ Parent / Guardian _______ Home address __________________________________________________________________ Phone _______________ Date of Claim _______________ Date of Incident ________________

1 . Statement of Incident / Issue ( include all pertinent information : who , how , where , when , how often , feelings , witness ).

2 . Please attach any additional information / documentation as necessary .

Signature of Presenter : ___________________________________________________________ Signature of Civil Rights Coordinator : ______________________________________________ Date Received : ____________________

Forms are available from either of the Civil Rights Coordinators , Administrators and Guidance Offices .

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