School Note School Name: ________________ Beginning Date: __________________

Student Name:_____________ Ending Date: ____________________

TEACHER: Please sign when the student attends class. Also, circle the "+" (positive) or "-" (negative) symbols to indicate how the student is academically progressing at this point in the semester. Note: You’re reporting on two areas: 1) signing for attendance and 2) circling for academic progress.

STUDENT: Get signed every day in every class and return form each week. Return form whether you’re doing well, and even when you’re not.

Monday Tuesday Wednesday Thursday Friday

1. Teacher (Class)

________________

Attendance - Initial _______ _______ ________ _______ ______

Academics - Circle + OR - + OR - + OR - + OR - + OR -

2. Teacher (Class)

________________

Attendance - Initial _______ _______ ________ _______ ______

Academics - Circle + OR - + OR - + OR - + OR - + OR -

3. Teacher (Class)

________________

Attendance - Initial _______ _______ ________ _______ ______

Academics - Circle + OR - + OR - + OR - + OR - + OR -

4. Teacher (Class)

________________

Attendance - Initial _______ _______ ________ _______ ______

Academics - Circle + OR - + OR - + OR - + OR - + OR -

5. Teacher (Class)

________________

Attendance - Initial _______ _______ ________ _______ ______

Academics - Circle + OR - + OR - + OR - + OR - + OR -

6. Teacher (Class)

________________

Attendance - Initial _______ _______ ________ _______ ______

Academics - Circle + OR - + OR - + OR - + OR - + OR -

TOTALS (Completed By LaRose):

Days Attended 100% ____ Days Attended 50% ____ Days Attended 30% ____

Each Day 100% +:____ Each Day 50% +:____ Each Day 30% +: ____

Contract

Goal Week One: ________

Positive in attendance 90% & Positive in Progress 40%

Goal Week Two: _________

Positive in attendance 90% & Positive in Progress 55%

Goal Week Three: ________

Positive in attendance 95% & Positive in Progress 65%

Goal Week Four: _________

Positive in attendance 95% & Positive in Progress 75%

Goal Week Five & Beyond: ______

Positive in attendance 98% & Positive in Progress 90%

====== Goals Accomplished ======

Goals Met or Not Met will determine:

Extra Sweet Snacks, Allowance Bonus, Cell Phone Use, CD Player Use EACH WEEK. If goals are NOT met in one week, determined USE will reduce (or be progressively limited as needed), until the next week's goals are met. At the end of the nine weeks, if attendance and grades show marked overall improvement one USA Flag Beany Baby will be provided at the school.

Agreement Signatures:

Student Sign:_______________________________

Parent Sign:______________________________

Kurt LaRose:_______________________________

Date Signed: ________________________________

Parent contact #1: Parent contact #2:

Parent contact #3: Parent contact #4:

Follow-up Meeting #1: Follow-up Meting #2:

“School Note” and “Contract” Copyright © 2006 – 2007, Kurt LaRose. Tallahassee, Florida 32303. A full reproduction and modification release is granted to all school districts contracting with LaRose for Counseling Services Program or any in-services and training seminars including those approved for professional development credits. The full reproduction release if valid for 12 months from the original date of the most recent contract for services. All other use is strictly and expressly prohibited.

| Behavior Record | Home | Email LaRose |