Region of Waterloo Form

Required fields are marked with asterisks (*)

Student No Smoking Or Vaping Violation Form

Student Name

Address

City

Mobile

Birthdate

Age

If Student Under 16: Parent/Guardian Name

Mobile

Home Phone

Work Phone

First Infraction. Consequences: A) TBD by School Administration.

Occurrence 1 Date

Occurrence 1 Time

Occurrence 1 Location

Witness 1 Name

Mobile

Witness 2 Name

Mobile

Was a vapour device e.g. electronic cigarette seized?

Yes

Was a tobacco product e.g. cigarettes seized?

Yes

Second Infraction. Consequences: A) TBD by School Administration, and B) Notification to Tobacco Enforcement Officer.

Occurrence 2 Date

Occurrence 2 Time

Occurrence 2 Location