Holley Central School District

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Online Bullying Report Form

Please use this form to identify instances of bullying that take place at Holley Central School District. Bullying should be reported whether it happens to you or you witness it. Instances of false reporting will be subject to disciplinary consequence.

Please tell us your name. Please note, this is required in order to process your request.

What happened to you or what did you witness? Be as specific as possible.

Name of student(s) who are bullying you or someone else.

Name of student(s) being bullied.

Name(s) of any witnesses.

Where did this incident take place?

When did this incident take place?

Do any adults in the building know about this? If yes, please provide name(s).

Your Name:

Your Email:

To validate your submission, please answer the following math problem: