<p> Confidential</p><p>TOMORROW RIVER SCHOOL DISTRICT Child Abuse/Neglect Reporting Form</p><p>School: Amherst Elementary Amherst Middle Amherst High </p><p>Student Name______</p><p>DOB ___/___/______Male____ Female____</p><p>Student Address ______</p><p>Name of student’s custodial parent:______</p><p>Phone number of custodial parent: ______</p><p>Reason for Report: Include reason for concern, date of incident, and any observations or pertinent information.</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______If necessary, continue report on the back of this form.</p><p>Report made by: ______</p><p>Position: ______</p><p>Date: ____/____/______Time: ______a.m p.m.</p><p>Portage County Health and Human Services phone number: 715-345-5350 Select option 3- “Calling to report child abuse or neglect, parent-child conflict, or any other child welfare concern.” You will be asked to provide the student information from above. </p><p>*Optional, but highly recommended: give original or copy to appropriate Administrator and/or School Counselor Confidential</p><p>**Remember this is a confidential form. It should be stored or destroyed appropriately.</p>
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