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*

MaleFemaleNon-Binary
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:

YesNo
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:*

YESNO
If YES to meeting held, select date:

MonthDayYear
Date
A phone conversation occurred (not a message left):*

YESNO
If YES to phone conversation, select date:

MonthDayYear
Date
A home visit occurred:*

YESNO
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?*

YesNo
Does the student have a 504?*

YesNo
Does the student have a health plan?*

YesNo
Has the student qualified for McKinney-Vento?*

YesNo
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