This document was written by me in hopes of providing a formal document for students who wish to request reinstatement to our district following an expulsion. We take expulsions very seriously and thus desire to be sure that we are providing fair and equitable protocol for all parties involved. I have found this petition to work well and feel it has served the purpose of providing a fair and comprehensive assessment of each petitioner, while maintaining the integrity of our district discipline policies.
Petition for School Reinstatement
Madison District Schools
Name of Petitioner: _________________________________________________________________________________________
(Parent/Guardian of student)
Address: ___________________________________________________________________________________________________
Phone #: ________________________________
Student Name: _________________________________________________________________________ Age: _____________
(Student expelled
Address: ___________________________________________________________________________________________________
Phone #: _________________________________________
Date of expulsion: __________________________________
Reason for Expulsion:
1) Has the expelled student received counseling or assistance from a social services agency?
If so, explain –
2) Was any criminal or court action taken against the expelled student since or because of the incident that caused the expulsion?
If so, explain –
3) Is the expelled student on probation?
If yes-
Name of Probation officer: ___________________________________________________________
Phone #: ________________________________________
4) Is the expelled student still involved in any criminal or court action?
If yes, explain –
5) Describe the expelled student’s attitude and behavior since the incident that caused the expulsion.
6) How and why do you think the expelled student will be successful if reinstated?
7) Please attach a letter of reference from a counselor or social worker that has been working the expelled student.
Signature of Petitioner: _________________________________________________________________________
Signature of Expelled Student: ___________________________________________________________________
Date: _______________________________________
Petition for School Reinstatement
Madison District Schools
Name of Petitioner: _________________________________________________________________________________________
(Parent/Guardian of student)
Address: ___________________________________________________________________________________________________
Phone #: ________________________________
Student Name: _________________________________________________________________________ Age: _____________
(Student expelled
Address: ___________________________________________________________________________________________________
Phone #: _________________________________________
Date of expulsion: __________________________________
Reason for Expulsion:
1) Has the expelled student received counseling or assistance from a social services agency?
If so, explain –
2) Was any criminal or court action taken against the expelled student since or because of the incident that caused the expulsion?
If so, explain –
3) Is the expelled student on probation?
If yes-
Name of Probation officer: ___________________________________________________________
Phone #: ________________________________________
4) Is the expelled student still involved in any criminal or court action?
If yes, explain –
5) Describe the expelled student’s attitude and behavior since the incident that caused the expulsion.
6) How and why do you think the expelled student will be successful if reinstated?
7) Please attach a letter of reference from a counselor or social worker that has been working the expelled student.
Signature of Petitioner: _________________________________________________________________________
Signature of Expelled Student: ___________________________________________________________________
Date: _______________________________________