FY 19 Truancy Referral Form
Referral Number *
Please begin with 1st referral for the 2018-2019 school year.
Student Last Name *
Your answer
Student First Name *
Your answer
Student Middle Initial or Name
Your answer
SIS Number *
State SIS number
Your answer
Grade Level *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Ethnicity *
To your knowledge has this student been referred for truancy services in past school years?
Special Ed *
Is there DCFS involvement with the student? *
Is student on court Supervision or probation?
Check here if student receives free lunch and/or public aid.
Check all that apply
Referring School Name *
If this referral is from an alternative school, what is the student's Home District and School? *
Days Enrolled *
Number of Days
Your answer
Days Excused *
Number of days excused absent
Your answer
Days Unexcused *
Number of days unexcused absent
Your answer
Credits needed to Graduate? *
High School Students Only
Your answer
Name(s) of Parent/Guardian *
Your answer
Physical Address *
Add directions if necessary
Your answer
City, State Zip *
Your answer
Mailing Address
Only complete if different from physical address
Your answer
Home Phone *
Your answer
Parent Work Phone
Your answer
Alternate Phone
Your answer
Other contacts
Your answer
Does the student have siblings in the district? If so, what are their names?
Your answer
Referral Person's Name *
Your answer
Referral Person's Position *
Your answer
Referring Person's Email *
Your answer
Referring Person's Phone Number
Your answer
Primary Referral *
Secondary Referral *
Referring school checks all that apply.
Required
Additional Comments
Your answer
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