Student:                                                    
	Teacher:                                                   
	 
	Date:                                                         
	 
	Students who access restricted items on the Internet are subject to the appropriate action described in the school's discipline policy or student handbook or to the following consequences: 
	                First Offense: 
	The above student has violated the Student Internet Policy by intentionally accessing restricted material.  He/she may lose Internet access for up to three weeks at the discretion of the supervising teacher.  A second offense will result in the student losing Internet access for a period                    .    
	                       
	               Second Offense: 
	The above student has violated the Student Internet Policy by intentionally accessing
	restricted material for a second time.  As a consequence of this violation the above student has lost Internet access for a period                     .      
	                     
	              Third Offense: 
	 
	The above student has violated the Student Internet Policy by intentionally accessing 
	restricted material for a third time.  As a consequence of this violation the above student has forfeited all Internet privileges for a period of                               or the balance of the school year.