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Erin's Law Referral Form



Erinís Law is a state mandated, age appropriate sexual abuse and assault awareness and prevention education program for students Pre-K through 12th grade. Erinís Law requires that children be educated by law in schools on sexual abuse in a child friendly manner, for the purpose of informing and protecting students from sexual abuse. Warning signs of abuse include, but not limited to, the following: prolonged depression or withdrawal from family and peers, displays knowledge or interest in sexual acts that are inappropriate for his/her age, makes strong efforts to avoid a specific person without an obvious reason, runs away from home, signs of physical discomfort, aggressive behavior towards others, and mistreatment of animals and other children.

To report a sexual abuse situation as described above, please complete the ďErinís Law Referral FormĒ below and submit. Chelsea Intermediate School appreciates your communication and support in ensuring the safety and welfare of all students.

Person reporting:
Relationship to student
Grade level:
Phone number:
Email:
Student Name:

Please describe the sexual abuse incident including when and where the abuse took place. Please include as much information as you know.


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