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

Name of the bully:*

Answer Required

Type of Bullying:*

Select all that apply.

Answer Required

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

Please list any and all witnesses to this event:

Answer Required

What did you do to help the situation?

Answer Required

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

Please fix the highlighted areas below before submitting.

Apollo-Ridge Middle School Bully Referral Form