Attendance Assistance Referral

Attendance Assistance Program
Email for Person Submitting Form:*
This will email you a copy of the form once complete
Student Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

City, ST, ZipState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
Gender*

MaleFemale
Ethnicity*

Hispanic or LatinoAmerican Indian or Alaskan NativeBlack/African AmericanAsianWhiteNative Hawaiian/Pacific Islander2 or more races
Lives with (Last, First, MI)*
Relationship*

Both ParentsSingle Parent MotherSingle Parent FatherFoster CareGuardianOther
Parent Phone Number*
Parent E-mail
example@example.com
Parent ESL (Spanish primary language)*

YesNo
Emergency Contact*
Emergency Phone*
Current Year School Entry Date*

MonthDayYear
Date
District*
School *
Example: Mark Twain, 111
State Student ID*
9 digit state ID
I-KAN Case Worker
Immunizations*

YesNo
Physicals*

YesNo
Lunch*

FreeReducedNo subsidy
Grade Level*
For Grades 9-12 Remaining Credits Needed to Graduate
Special Ed*

YesNo

The Illinois School Code requires schools to take measures to assist the student and his/her family in resolving an attendance problem. Documentation of at least three different interventions is necessary. Effective 2-1-23, at least one intervention must be a verbal or face-to-face communication with the parent/guardian. Please note DATES in the spaces below. If you have additional documentation you may provide it to the caseworker.*

	Date
Attendance Warning Letter Sent
Teacher/Office phone call
Principal/Social Worker phone call
Conference with Student
Special Incentives set up
Current Placement Pending
Student meets with Social worker/Counselor/SEL
Information/referral to community resource
Conference with Parents
Schedule Changes
Home Visits
Other (Describe)

Pre-Attendance Data (Student's attendance from the first day of school until the referral date)
Referral Date*

MonthDayYear
Date

Current Pre-Attendance Data

	Total Days	Days Present	Excused Absent	Unexcused Absent	Suspended	Tardies
Current School Year

Participation Status (Leave Blank if unsure)

NewOld
Primary Referral (Leave blank if unsure)

Truant (unexcused 1-8 days)Chronic Truant (unexcused 9 or more days)Potential DropoutDropout
Secondary Referral (Select any that apply. Leave blank if unsure)

Low AchievementHigh Failure rate (3 or more classes)Teen ParentCredit DeficientLow IncomePhysical/Emotional Health ProblemsCourt/Law Mandated participationDrugs/AlcoholTardinessOther Referral
Please attach student's attendance sheets from Present AND Previous School Year. (180 days of attendance)*

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Attendance Assistance Program