School Truancy Referral Form
PART I
Student_______________________,________________________________________________
(last name) (first name) (middle name)
Grade: _______________ Age: _________________ DOB: ________________________
Mother’s Name: ___________________________ DOB: _____________________________
Phone: ___________________________ Wk. Phone: _______________________________
Address: _________________________ City: _____________________ Zip: ___________
Father’s Name: ___________________________ DOB: ____________________________
Phone: ___________________________ Wk. Phone: _______________________________
Address: _________________________ City: _____________________ Zip: ___________
Child resides with: _______________________________________________
Address (if different than above): ________________________________ Zip: ___________ Phone: ___________________________________
PART II
Enrollment Date: ______________ Number of Tardies: _________________________
Number of Absences: With a Valid Excuse: _________ Without a Valid Excuse: _________
Dates Child was Absent from School without Valid Excuse:
Suspension/Expulsion Dates: _____________________________________________________
Contacts with Parents, Actions Taken, and Outcomes (attach additional sheets if necessary): Date:_________________________________________________________________________ Date:________________________________________________________________________ Date:_________________________________________________________________________
Date:_________________________________________________________________________
Advisory Letter Sent? No _____ Yes _____ Date:_________________________
School Representative (person who can testify to the identification of the child, enrollment, keeping of records, and content of records): __________________________________________
PART III: REFERRING SCHOOL INFORMATION
School Name: RISE Charter School
Telephone: _______________________
Address: ________________________________________________
City & State: _______________________ Zip: _______________
_____________________________________ ________________________________
(Print name of person submitting report) (Title and Position)
_____________________________________ _________________________________
(Phone) (Signature)