School Name First Name Last Name Date of Incident THE SCHOOL DISTRICT OF PALM BEACH COUNTY DEPARTMENT OF SAFE SCHOOLS School-Based Stay Away Agreement This agreement is to be completed with school administration in a conference with the alleged aggressor and his/ her parent or guardian. Student ID # Date of Parent/Guardian Notification Date of Conference with Parent/Guardian Description of relationship between the parties School-Based Stay Away Agreement Alleged Agreesor's Name I, , agree to: Stay feet from Student Victim's Name at all times during the school day or on school district property or at school related functions (i.e., all school buildings, grounds, bus stops, school buses, school vehicles, school contracted vehicles, or any other vehicle approved for school purposes; area of entrance/departure from school grounds, premises or events; and all school sponsored activities, events or trips; and walking routes to or from school for the purposes of attending school or school sponsored functions, events or trips). Refrain from talking to, emailing, calling, text messaging, sending messages to or in any other form to Student Victim's Name Inform the school administration of changes to my schedule and extra-curricular activities. PBSD 2507 (Rev. 7/23/2015) Page 1 of 2 COPY- Principal, School Counselor, School Police Officer, Parent Signature of Student Date . Has a court order for protection been issued between the two parties? Yes No RECORDED COPY- Cum folder