Truancy Referral Form FY 20
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Referral Number *
Please begin with 1st referral for the 2019-2020 school year.
Student Last Name *
Student First Name *
Student Middle Initial or Name
SIS Number *
State SIS number
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?
Clear selection
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
Days Excused *
Number of days excused absent
Days Unexcused *
Number of days unexcused absent
Credits needed to Graduate? *
High School Students Only
Name(s) of Parent/Guardian *
Physical Address *
Add directions if necessary
City, State Zip *
Mailing Address
Only complete if different from physical address
Home Phone *
Parent Work Phone
Alternate Phone
Other contacts
Does the student have siblings in the district? If so, what are their names?
Referral Person's Name *
Referral Person's Position *
Referring Person's Email *
Referring Person's Phone Number
Primary Referral *
Secondary Referral *
Referring school checks all that apply.
Required
Additional Comments
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