JGG-R

Physical Restraint Notification and Permission Form

I have received Rochester School Department's policy on physical restraint of students; it has been

explained to me and I understand it. As the parent/guardian of

Student's Name

I hereby:

 grant

 do not grant

authorization for the Rochester School Department to use physical restraint techniques with the

above student as described in said policy.

Parent/Guardian Signature Witness

Date

Adoption Date: October 14, 1993

Amended: May 13, 2004

Amended: May 12, 2011