Education Complaint Form

Thank you for your response. ✨

The Santa Rosa – Sonoma County NAACP works to ensure that students who are most disproportionately impacted by school policies have access to great teaching, equitable resources, and a challenging curriculum. We are dedicated to eliminating the severe racial inequities that continue to plague our education system. Our ultimate goal is that every students receive a quality education that prepares them to be a contributing member of a democracy.

The person who experienced the problem should normally fill in this form. If you are making a complaint on behalf of someone else please fill in Section B also.

Your First Name

Your Last Name

Mailing Address

Mailing Address Line 2

City

State

Email Address

Contact Number

Which Best Describes You?

First Name of Complainant

Last Name of Complainant

Which is your relationship with the Complainant

Do we have permission to Advocate/Speak to District Representatives (including Superintendent, Principal, teachers Etc.) on your behalf?

Which is the Student’s grade Level?

Does the Student have an IEP/504

What is the name of the school you are complaining about?

If other, please explain below.

What date did this incident occur? (YYYY-MM-DD)

What time did this incident occur?

Describe what happened, and how this incident has affected you.

Did you file a complaint with the school?

To whom did you report this incident, and what was their response?

What would you like the NAACP to do for you regarding the incident(s)?

I do hereby authorize the NAACP Legal Redress Committee to investigate my complaint and to take any steps necessary to resolve it, and I understand that the NAACP is not a legal entity and that the organization has certain limitations as to the scope of their Influence and ability.

RELEASE OF LIABILITY: (A) I affirm that the statements that I have made above are accurate and true to the best of my knowledge and belief. (B) I hereby request the assistance of the Santa Rosa – Sonoma NAACP in seeking a remedy to the situation described above. (C) I hereby authorize the officers of the Santa Rosa – Sonoma Branch Unit # 1074 to have access to information and documents, which are relevant to my claim of discrimination described above. (D) I understand that once a referral has been made to a volunteer, community agency or private attorney, the Santa Rosa – Sonoma NAACP Branch WILL NOT BE RESPONSIBLE for handling this matter. (E) In fact, I further understand that by signing this document, I am agreeing to HOLD the Santa Rosa – Sonoma NAACP Branch harmless for all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.

NON-RETALIATION REQUIREMENTS

Section 704 (a) of the Civil Rights Act of 1964, (as amended), Section 4 (d) of the Age Discrimination in Employment Act of 1967, (as amended), and various other civil rights laws make it an unlawful employment practice for an employer; employment agency; or labor organization: to discriminate against employees, applicants for employment, member or applicant for membership, because the employee, member or applicant has opposed an unlawful employment practice, made a charge, testified, assisted, or participated in any manner in an investigation, proceeding or hearing.

COMPLETION OF THIS FORM

Completing this form does NOT constitute filing an official complaint with a legal authority. At this time the Branch is ONLY seeking information to assist you concerning this complaint. Please mail this information and copies of sustaining documents in an envelope marked “CONFIDENTIAL” to the Branch at PO Box 3964 | Santa Rosa, CA 95402

Guardian/Care taker Signature

Date (YYYY-MM-DD)

Education Complaint Form

Thank you for your response. ✨

Share this:

Like this: