2017-8 Request for Truancy Service
DeWITT, LIVINGSTON, LOGAN & 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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County
Name of School:
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Principal Name:
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School Address:
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School City:
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School State:
Required
School Zip Code:
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School Phone Number:
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Student Data
Student's First Name:
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Student's Last Name:
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SIS:
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Grade
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Sex:
Date of Birth:
MM
/
DD
/
YYYY
Student lives with:
Is student a high school student?
If yes, credits needed to graduate
Your answer
Court involvement:
If Yes, Explain:
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Parent Data:
Parent/Guardian Name(s):
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Parent Address:
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Parent City
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Parent State
Required
Parent 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:- NA if not available
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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.) Please forward this to truancy@roe17.org
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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Total Absences All-Together
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School/District Interventions:
Please include dates. Attach documentation. A social history of student may be required. Please forward this to truancy@roe17.org
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
Please send your Student Attendance Record and School District Intervention documentation to email it to truancy@roe17.org
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