Attendance Support Student Referral Form

Attendance Support Student Referral Form
District # and Name
Student

First NameLast Name
Date of birth

MonthDayYear
Date
REMINDER: School attendance is mandatory in IL for children ages 6-17 years old.
Grade
Gender
Student's Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone

Area CodePhone Number
School Attending
School Address

Street Address

Street Address Line 2

CityState

Zip Code
School Phone

Area CodePhone Number
Date Enrolled

MonthDayYear
Date
Parent/Guardian

First NameLast Name
Relation
Parent/Guardian's Phone

Area CodePhone Number
Does the Parent/Guardian live with the student:
Parent/Guardian's email (if known)
example@example.com
Missed Attendance Days/Dates – REQUIRED

Please enter the days/dates for student's FULL DAY SCHOOL ABSENCES ONLY (excused and/or unexcused).
Days Absent – Excused
Days Absent – Unexcused
Dates
Partial Days Truant
Do not count sick, excused, or suspended days as truant. If no partial days, please enter 0.
Dates Truant - Partial Days
If no partial days, please type N/A.
Actions taken
Please describe
The Illinois School Code requires schools to take measures to assist the student and his/her family in resolving attendance issues.

It is a requirement to have three (3) interventions. Please fill in the intervention dates and upload your intervention documentation below.
1st Intervention
Date of 1st intervention:

MonthDayYear
1st intervention documentation - upload file:

Upload

Cancelof
2nd Intervention
Date of 2nd intervention:

MonthDayYear
2nd intervention documentation - upload file:

Upload

Cancelof
3rd Intervention
Date of 3rd intervention:

MonthDayYear
3rd intervention documentation - upload file:

Upload

Cancelof
Interventions
Please type N/A if you have no other interventions to report.
A meeting was held with the family:
If YES to meeting held, select date:

MonthDayYear
Date
A phone conversation occurred (not a message left):
If YES to phone conversation, select date:

MonthDayYear
Date
A home visit occurred:
If YES to home visit, select date:

MonthDayYear
Date
Barriers to Attendance

As this section is not required, please complete the best you can as it will help us to identify the needs for the student and family.
Transportation Issues:
Health Issues:
Academic/School Issues:
Social Issues:
Home Issues:
Safety Issues:
Other Issues:
SCHOOL CONTACT #1
Name
Email
example@example.com
Position
Phone

Area CodePhone Number
SCHOOL CONTACT #2
Name
Email
example@example.com
Position
Phone

Area CodePhone Number
PLEASE NOTE: North Cook ROE/ISC staff will contact the referral source within a week. If no response is received by North Cook from the contact within a week, the referral will be dropped.
Language Spoken at Home
Does the student have an IEP?
Does the student have a 504?
Does the student have a health plan?
Has the student qualified for McKinney-Vento?
Up to date attendance report:

Browse Files
Please upload the most current attendance report for the student Cancelof
Enter the message as it's shown
Should be Empty:

Attendance Support Student Referral Form

1st Intervention

2nd Intervention

3rd Intervention