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Student No Smoking Or Vaping Violation Form

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

Was a vapour device e.g. electronic cigarette seized?
 
Was a tobacco product e.g. cigarettes seized?
 

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

Was a vapour device e.g. electronic cigarette seized?
 
Was a tobacco product e.g. cigarettes seized?
 

Third Infraction. Consequences: A) TBD by School Administration, B) Notification to Tobacco Enforcement Officer, laying of charges possible.

Willing to be a witness in court?
 
Willing to be a witness in court?
 
Was a vapour device e.g. electronic cigarette seized?
 
Was a tobacco product e.g. cigarettes seized?
 

Reported By

Title

Minimum characters: 2

Clear
For more information please call Region of Waterloo at (519) 575-4400 or TTY (519) 575-4608. 
Form 3122246 v1
 


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