DREAM13 Foundation

Value Students Initiative Form

This form is for any Marietta City Schools student from 2007-present. Please fill it out if you feel your
player has experienced any of the behaviors outlined in the questions. This form is 100% confidential.
None of your identity information will be shared with any school administrators or coaches. Your
personal identity is only visible to the DREAM13 officer gathering the data. We will only disclose who
you are if you grant us permission later if needed in the investigation process. There is zero fear of
disclosure or retaliation filling out this form. The purpose for the data gathering is so that everyone has
the ability to share their experience in a safe way and so that we can use that information to shape the
student’s environment and district policy moving forward. Thank you for participating. Your story will
change the future for our kids. You are not at fault for this happening and there is nothing to fear by
coming forward.

*This form can be filled out by parent/guardian, grandparent, or student

Player Name _______________________________________________

Parent/Guardian Name ________________________________________________

1. Has your child ever been the target of bullying, harassment, or intimidation as defined by Ohio
Revised Code which states, “any intentional written, verbal, electronic, or physical act which causes
mental or physical harm more than once.”? YES/NO

2. Has your child ever been the subject of abuse as defined by the CDC as, “any acts by any caregiver
such as a coach or teacher that results in physical or mental harm, potential harm, or threat of harm to a
child.”? YES/NO

Grade at time of incident(s):________________________

Sport:__________________________

Offending Coach(es): ______________________________________________________

Please provide a brief summary of what happened:___________________________________________

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Do you have additional instances that you could share? YES/NO

Value Students Initiative Form Continued

3. Did you inform other coaches, Principal, Athletic Director, Superintendent, or Board Member of the
offending behavior? YES/NO

4. Who did you inform?_____________________________________________

5. What was the feedback/result you received?______________________________________________

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6. Do you feel neglected or ignored by the administrators regarding the complaint you filed? YES/NO

7. Have you personally witnessed other players being subjected to abuse, bullying, intimidation, or
harassment by another coach as defined above? YES/NO

8. Have you personally witnessed coaches directing profanity at players? YES/NO

9. Please share anything else that you have personally witnessed by a coach that you feel is
inappropriate. ________________________________________________________________________

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10. Do you feel like the current administrators are concerned for your safety and well-being? YES/NO

11. May we contact you for additional information if needed? YES/NO

NAME OF PERSON FILLING OUT THIS FORM

_______________________________________________

TODAY’S DATE

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CONTACT INFO (will not be used by any third party)

PHONE _________________________

EMAIL _______________________________________________________________