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*
Format: (000) 000-0000.
Parent E-mail
example@example.com
Parent ESL (Spanish primary language)*

YesNo
Emergency Contact*
Emergency Phone*
Format: (000) 000-0000.
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.*

Rows	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

Rows	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