Student Information

Student name:*

Student date of birth: (mm/dd/yyyy)*

Address:*

City:*

State:*

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ZIP Code:*

Telephone number:

Gender:*

Male Female Other

Native American child?*

Yes No

Has there been involvement with a probation officer or county social worker over the past year?*

Yes

No

If so, please provide the following information.

Name:

Contact number:

County:

Family Information

Guardian #1 name:

Address:

City:

State:

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ZIP code:

Home phone:

Cell:

Email Address:

Guardian #2 name:

Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip:

Home phone:

Cell:

Email Address:

School Information

School name:*

School address:*

City:*

State:*

Zip:*

Student's current grade level:*

Credits earned to date:*

Required credits to graduate:*

On track to graduate

Yes

No

List classes student enjoys or is passing:*

Anticipated graduation date:*

List classes student is failing:*

School Attendance
**Please note when calculating the number of days absent below that pursuant to Minn. Stat. §260C.007 Subd. 19 a day of unexcused absence is defined as being absent without lawful excuse for the entire school day if in elementary school or one or more class periods per day if the child is in middle school, junior high school, or high school.

Current School Year

Number of days with an excused absence*

Number of days with an unexcused absence:*

Previous School Year (if available):

Number of days with an excused absence:

Number of days with an unexcused absence:

Grade when significant changes first occurred:*

Has Truancy been filed in the past:

Yes

No

If yes, year:

County:

Additional Information:

Does the family read, speak, and understand English:*

Yes

No

Interpreter needed:*

Yes

No

If yes, language:

Who in the family needs an interpreter:

Have the parents been notified that this complaint is being filed?*

Yes

No

Is there an IEP or 504 for the student?*

Yes

No

Date School Support Plan was initiated?*

Was Student involved?*

Was Parent involved?*

Have 45 days elapsed since the School Support Plan was initiated?*

Yes

No

If it has been less than 45 days or a School Support Plan was not initiated, document the reasons why:

Has the family been given a copy of the SC Truancy Brochure?*

Yes

No

Attach and check off all of the following that pertain to this student at time of Offense Report submission

Current Attendance Report All letters sent to parent(s) regarding attendance Individual Education Plan (IEP) Required County Truancy Statute Letter that was sent to parent(s) referring to 260A.03

Copy of Attendance Policy (required for all online students) Current Disciplinary Record Copy of School Support Plan 504 Accomodation Plan

***ATTACH ATTENDANCE PRINT OUT WITH DATES HIGHLIGHTED AND AN EXPLANATION OF CODES AND ANY OTHER RELEVANT ATTACHMENTS BELOW***

Have you referred to Restorative Circle?*

Yes

No

Why or why not?*

Have you referred to Tree House Out Reach?*

Yes

No

Why or why not?*

Attachment:

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Attachment:

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Attachment:

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Please describe all efforts to engage the student and family before making this referral as well as anything else relevant to assisting us in working effectively with the student and family:*

Are there any cultural considerations or needs that the County should know about?*

Name/Title of School Representative completing this referral:*

Email Address:*

Phone number:

Date of Truancy Referral Submission:

Name/Title of School Contact Person (if different)

Email Address:

Phone number: