Attendance Assistance Program
Email for Person Submitting Form:
*
This will email you a copy of the form once complete
Student Name
*
First Name
Middle Initial
Last Name
Address
*
Street Address
Street Address Line 2
City, ST, Zip
State / Province
Postal / Zip Code
Birth Date
*
/
Month
/
Day
Year
Date
Gender
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Male
Female
Ethnicity
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Hispanic or Latino
American Indian or Alaskan Native
Black/African American
Asian
White
Native Hawaiian/Pacific Islander
2 or more races
Lives with (Last, First, MI)
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Relationship
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Both Parents
Single Parent Mother
Single Parent Father
Foster Care
Guardian
Other
Parent Phone Number
*
Parent E-mail
example@example.com
Parent ESL (Spanish primary language)
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Yes
No
Emergency Contact
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Emergency Phone
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Current Year School Entry Date
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/
Month
/
Day
Year
Date
District
*
Please Select
4 -Clifton Central
6 -Cissna Park
6 -Grant Park
53 Bourbonnais Elementary
307 -BBCHS
61 -Bradley
2- Herscher
111- Kankakee
5 -Manteno
258 -St George
1 -Momence
259 -Pembroke
24 -St Anne
249 -Crescent City
3 -Donovan
9 -Iroquois County (Watseka)
10 -Iroquois West
124 -Milford
School
*
Example: Mark Twain, 111
State Student ID
*
9 digit state ID
I-KAN Case Worker
Please Select
Cynthia Bauman
Noelle Bradley
Sara Christensen
Jordyn Clark
Kayla James
Stacia Sellers
Racheal Smith
Raphael Smyly
Immunizations
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Yes
No
Physicals
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Yes
No
Lunch
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Free
Reduced
No subsidy
Grade Level
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Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Freshman
Sophomore
Junior
Senior
For Grades 9-12 Remaining Credits Needed to Graduate
Special Ed
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Yes
No
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.
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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
*
/
Month
/
Day
Year
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)
New
Old
Primary Referral (Leave blank if unsure)
Truant (unexcused 1-8 days)
Chronic Truant (unexcused 9 or more days)
Potential Dropout
Dropout
Secondary Referral (Select any that apply. Leave blank if unsure)
Low Achievement
High Failure rate (3 or more classes)
Teen Parent
Credit Deficient
Low Income
Physical/Emotional Health Problems
Court/Law Mandated participation
Drugs/Alcohol
Tardiness
Other Referral
Please attach student's attendance sheets from Present AND Previous School Year. (180 days of attendance)
*
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