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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 (
Antionette Bedessie (
Knetra Nelson ( )

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Complainant Name(Required)
Respondent Name (Person whom complaint is against)
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Signature Authorization(Required)

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First Lastname