Revised: 8-10-11


Statement of Commitment


I, ______________________(student’s name), have been informed by my

 (coach/advisor/supervisor), of District Policy JGA which prohibits bullying, cyber bullying,

 harassment, hazing, retaliation, and any initiation activities. As a condition of my participation

 in __________________________ (name of team or group), I agree to abide by this Policy and

 refrain from the aforementioned illegal activities and any initiation activities of any kind. I

 understand that my involvement in these illegal activities will result in disciplinary action,

 which may include, but not limited to, verbal reprimand, probation, suspension from school, loss

 of participation, exclusion from extra-curricular activities, criminal prosecution, and/or


________________________________            ___________________

(Signature of Student)                                    (Date)



As a parent/guardian of a student, I have also been informed of the District Policy JGA prohibiting bullying, hazing and initiation activities and will encourage my child to comply.

________________________________            ___________________

(Signature of Parent/Guardian)                                    (Date)

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