Attendance Referral Form
Today's Date
-
Month
-
Day
Year
Date
School Building (District)
*
Please Select
Bath Elementary School (Bath Community Schools)
Bath Middle School (Bath Community Schools)
Bath High School (Bath Community Schools)
Schavey Road Elementary (DeWitt Public Schools)
Scott Elementary (DeWitt Public Schools)
Herbison Woods Elementary (DeWitt Public Schools)
DeWitt Middle School (DeWitt Public Schools)
DeWitt High School (DeWitt Public Schools)
Waldron Elementary (Fowler Public Schools)
Waldron Middle School (Fowler Public Schools)
Fowler High School (Fowler Public Schools)
Leonard Elementary (Ovid-Elsie Area Schools)
EE Knight (Ovid-Elsie Area Schools)
Ovid-Elsie Middle School (Ovid-Elsie Area Schools)
Ovid-Elsie Alternative High School (Ovid-Elsie Area Schools)
Ovid-Elsie High School (Ovid-Elsie Area Schools)
Pewamo Elementary (Pewamo-Westphalia Community Schools)
Pewamo-Westphalia Middle School (Pewamo-Westphalia Community Schools)
Pewamo-Westphalia High School (Pewamo-Westphalia Community Schools)
Eureka Elementary (St. Johns Public Schools)
Gateway Elementary (St. Johns Public Schools)
Oakview Elementary (St. Johns Public Schools)
Riley Elementary (St. Johns Public Schools)
St. Johns Middle School (St. Johns Public Schools)
St. Johns High School (St. Johns Public Schools)
STRIVE Academy (St. Johns Public Schools)
St. Peter Lutheran
St. Joseph Pewamo
St. Mary's Westphalia
St. Joseph St. Johns
Most Holy Trinity Fowler
Other: list below
Other School
School Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
District Contact Person
*
District Contact Person's email address
*
(A copy of this form will be emailed to the District Contact Person)
District Contact Person's Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Student Information
Student Name
*
First Name
Middle Name
Last Name
Suffix
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Age
Ages 5-18
Student Grade
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Student Gender
Male
Female
Referral Type
*
Please Select
Formal
Informal
(Formal indicating process toward court involvement)
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Student Phone Type
*
Home
Mother
Father
Other
Total Absences to Date
*
Total Unexcused Absences to Date
*
Reason for Referral
*
File Upload
Browse Files
Drag and drop files here
Choose a file
Link attendance records/reports & all (or most recent) letters sent to the parent/guardian by school personnel.
Cancel
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Is the student receiving Special Education Services?
*
Yes
No
Unknown
Is the student a Court Ward?
*
Yes
No
Unknown
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Parent/Guardian Information
Person 1's Name
*
First Name
Last Name
Person 1's Email
*
example@example.com
Person 1's Relationship to Student
*
Mother
Father
Guardian
Step Parent
Other
Person 1's Address
*
Same as Student
Different from Student
Person 1's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person 2's Relationship to Student
Mother
Father
Guardian
Step Parent
Other
Person 2's Name
First Name
Last Name
Person 2's Email
example@example.com
Person 2's Address
Same as Student
Different from Student
Person 2's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other information/Comments:
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Educational Problem Meeting Completed
*
Yes
No
Educational Problem Meeting Date
*
-
Month
-
Day
Year
Date
Educational Problem Meeting Participants
*
Educational Counseling Meeting Completed
*
Yes
No
Educational Counseling Meeting Date
*
-
Month
-
Day
Year
Date
Educational Counseling Meeting Participants
*
Is the student receiving counseling from an outside agency?
*
Yes
No
Outside Counseling Agency Information
*
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Submit
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