Title IX Formal Complaint Form Momentum Academy (“the [School/District]”) complies with federal and state laws prohibiting unlawful discrimination based on race, color, national origin, sex, disability, and age in its programs and activities. Any person that believes they have been harassed or discriminated against based on his/her sex can file a complaint under this procedure by contacting the School’s Title IX Coordinators: Nicole Lampert (Nicole.lampert@momentumacademystl.org) Antionette Bedessie (antionette.bedessie@momentumacademystl.org) Knetra Nelson (Knetra.nelson@momentumacademystl.org ) View Sexual Harassment Policy HereDate(Required) MM slash DD slash YYYY Complainant Name(Required) First Last Address(Required) Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone(Required)Respondent Name (Person whom complaint is against) First Last Describe the alleged sexual harassment in specific terms (attach additional pages if necessary). Please include the following: the specific incident or activity that is alleged to be in violation of Title IX The name of all individuals involved. Dates, times, and locations involved.(Required)Describe any relevant communication that has already occurred to address the issue. Please specify the types of communication, dates of communication, and names of individuals with whom any communication has occurred.(Required)Do you want this Complaint to be formally investigated and addressed by the School?(Required)YesNoIf “No”, please clarify:(Required)I do not want a formal investigation. I am just bringing this to the School’s attention.I do not want a formal investigation. I would like to speak with the Title IX Coordinator about my complaint.Other ((please explain)If Other was selected, please explain Electronic Signature(Required) Date(Required) MM slash DD slash YYYY Signature Authorization(Required) By checking this box I agree that the information provided is an accurate representation of my experience. I authorize Momentum Academy to reach out to me to follow up on this information using the contact method indicated above. CAPTCHASection Break