2016-7 Request for Truancy Service
DEWITT, LIVINGSTON & MCLEAN COUNTIES TRUANCY/OUTREACH PROGRAM REQUEST FOR INITIAL TRUANCY SERVICE
Failure to complete this referral in its entirety will cause this form to be returned to your for completing prior to processing your request for truancy services.
Your Name:
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Position:
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Email:
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Name of School:
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Student Data
Student's Name:
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SIS:
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Grade
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Sex:
Date of Birth:
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Student lives with:
Is student a high school student?
If yes, credits needed to graduate
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Court involvement:
If Yes, Explain:
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Parent Data:
Parent/Guardian Name(s):
Your answer
Parent Address:
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Parent City/Zip Code:
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Home phone:
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Father's work phone:
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Mother's work phone:
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Emergency number:
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Parent Email address:
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Student Assistance
A COPY of the STUDENT'S ATTENDANCE RECORD MUST BE ATTACHED. INCLUDE EXPLANATIONS OF ATTENDANCE CODE. (A minimum of four (4) unexcused absences must be documented prior to processing.)
Number of school days possible to date:
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Number of current year unexcused absences:
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Number of current year excused absences:
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School/District Interventions:
Please include dates. Attach documentation. A social history of student may be required.
Schedule Changes:
Explain:
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Free or Reduced Lunch:
Special Education Placement:
Type:
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Social Service Agency/Counseling involvement:
If yes explain:
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Additional Comments
Please use this section if you have any additional comments that you think will help us with this student.
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Please Remember
Fax your Student Attendance Record and School District Intervention documentation to 309.828.8564.
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