NOTE: You should submit this form online then fax documentation to the Regional Alternative School. See the bottom of the form for further details.

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 you for completion prior to processing your request for truancy services.
 

Your Name: 
Position: 

Email:

 

School & Address: 

School Name (if not in list):

 

STUDENT DATA:

Student's Name: 

SIS#: 

Grade: 

Sex:  Male    Female

Date of Birth: 

Student lives with:  Mother    Father    Both    Step-Parent/Guardian Other

 

Court involvement:  Yes    No

 

 If Yes, Explain:       

 

PARENT DATA:

Parent/Guardian Name(s): 

Home phone: 

Address: 

Father's work phone: 

City/Zip Code: 

Mother's work phone: 

 

Emergency number: 

 

STUDENT ASSISTANCE:

A COPY OF THE STUDENT'S ATTENDANCE RECORD MUST BE ATTACHED.  INCLUDE EXPLANATIONS OF ATTENDANCE CODE. (A minimum of nine (9) unexcused  absences must be documented prior to processing.)

  Previous year absences (unexcused)

  Number of current year class cuts

  Number of current year absences, unexcused

  Current year in-school, suspensions

  Number of current year absences, excused

  Current year out-of-school, suspensions

 

SCHOOL/DISTRICT INTERVENTIONS:

Please include dates. Attach documentation.  A social history of student may be required.

1.

Phone Calls to Parents (dates):

2.

Letters to Parents (dates):

3.

Conferences with student and parent (dates):

4.

Schedule Changes:  Yes    No    Explain: 

5.

Free or Reduced Lunch:  Yes    No

6.

Special Education Placement: Yes    No    Type: 

7.

Social Service Agency / Counseling involvement:  Yes    No

 

If Yes, Explain: 

 


Please remember to fax Student Attendance Record and School District Intervention documentation to 309.828.8564, Livingston County fax to 815.842.092.

 

 

Submit: