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Truancy Referral Form
Please fill out the form in its entirety. Do not leave any fields blank. If you don't know the answer to a question, put "unknown". Attach a copy of the student's most current attendance report and copies of doctor(s) excuse slips if applicable.
STUDENT'S INFO
Student's Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
Year
Gender
*
Male
Female
Preferred Pronouns
Primary Language Spoken
*
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Is the Student experiencing homelessness?
*
Yes
No
Unknown
Is the Student receiving services of any kind or been referred?
*
Yes
No
Unknown
What services? Include the agency and/or counselor name(s).
Is the Student involved with Juvenile Court (Circuit Court - Family Division)
*
Yes
No
Unknown
Probation Officer Caseworker's Name
Physical Description of the Student IF they are Age 11 and up:
PARENT / LEGAL GUARDIAN INFO
Parent / Legal Guardian #1
*
First Name
Last Name
Relationship to the Student
*
Cell or Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Are the Parent(s) / Guardian(s) cooperative with the school?
*
Yes
No
Unknown
Physical Description of the Parent/Legal Guardian IF the Student is UNDER the Age of 11:
Parent / Legal Guardian #2
First Name
Last Name
Relationship to the Student
Cell or Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
STUDENT'S SCHOOL INFO
School District
*
Please Select
Berrien RESA
Benton Harbor
Benton Harbor Charter
Berrien Springs
Brandywine
Bridgman
Buchanan
Coloma
Countryside
Eau Claire
Lakeshore
New Buffalo
Niles
Online / Other
River Valley
St. Joseph
Watervliet
School Building
*
Grade
*
Is the student classified as Special Ed?
*
Yes
No
Unknown
Does Special Ed eligibility need to be determined
*
Yes
No
Unknown
Should an IEP be called before making a truancy referral?
*
Yes
No
Unknown
Should the student be referred to an Alternative Education Program?
*
Yes
No
Is the student currently enrolled and attending?
*
Yes
No
Please explain the reason for the referral.
Is the student passing?
*
Yes
No
What are their grades? Check all that apply.
*
A's
B's
C's
D's
F's
ATTENDANCE INFO
Number of Days Absent
*
Total # of UNEXCUSED Days Absent
*
Is there a prior history of attendance problems?
*
Yes
No
Unknown
School Year a referral was made to Berrien RESA:
Are the Student's absences primarily related to illness?
*
Yes
No
Unknown
Are the Student's absences primarily related to suspensions?
*
Yes
No
Unknown
Were the Parent(s) / Legal Guardian(s) notified by letter that the school was obligated by law to make a truancy referral to Berrien RESA if attendance did not improve?
*
Yes
No
Upload all copies of letters sent, a copy of the most current attendance report and any doctor excuse slips if applicable.
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REFERERS INFO
Principal (not Vice or Assistant)
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Principal's Signature
*
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