Apollo-Ridge Middle School Bully Referral Form

Apollo-Ridge Middle School
Bully Referral Form

This is the Apollo-Ridge Middle School online "Bully Box" Referral Form. You still have the option of completing a paper/pencil referral and placing in our "Bully Box" locate in the Middle School Commons area.

Name of the person being bullied:*

Answer required for "Name of the person being bullied:"

Name of the bully:*

Answer required for "Name of the bully:"

Type of Bullying:*

Select all that apply.

Answer required for "Type of Bullying:"

Physical (Hitting, Kicking, slapping, getting another person to hit or harm the victim, or other physical aggression)

Verbal (Teasing, name calling, put-downs, or other verbal behavior that would hurt others' feelings or make them feel bad)

Emotional/Exclusion (starting rumors, telling others not to be friends with someone, harassment, intimidation, or other actions that would cause someone to be without friends)

Cyber Bullying (Using an electronic device to engage in any previously mentioned bullying)

Describe the events. What did the alleged offender do or say? Please describe with as much detail as possible. List any evidence, if any (Letters, photos, notes, etc.).*

Answer required for "Describe the events. What did the alleged offender do or say? Please describe with as much detail as possible. List any evidence, if any (Letters, photos, notes, etc.)."

Please list any and all witnesses to this event:

Answer required for "Please list any and all witnesses to this event:"

What did you do to help the situation?

Answer required for "What did you do to help the situation?"

Told a teacher

Told the guidance counselor

Told the principal

Told the bully to stop

Talked with the person being bullied

I did nothing, just reported the situation.

You have the option of submitting your name with this referral. If you don't, it is completely fine. If you choose to give your name, your identity will remain confidential.

Answer required for "You have the option of submitting your name with this referral. If you don't, it is completely fine. If you choose to give your name, your identity will remain confidential. "

Please fix the highlighted areas below before submitting.

Apollo-Ridge Middle School Bully Referral Form