Community Restitution Form

Thank you for serving as a Referral Supervisor for the student conduct process.  Please complete this form as soon as possible after the assigned deadline or when the hours have been completed, whichever is sooner.  Please contact Stephanie Shell ( or 276-328-0216) if you have any questions.

Referral Supervisor Information
Sanction Referral Information

Please check all that apply. List any specifics (number of hours, sessions, etc.) in the NOTES section at the bottom of the form.

Please list the number of completed hours, sessions, items here.