Form Center

2. Referrer Name*
3. Email Address
5. School Name and Address*
6. Online School*

   1. Yes
   2. No
8. City*
9. State*
10. Zip Code*
12. Phone Number*
13. Fax Number
17. Child's Legal Name*
18. Child's DOB*
    Child's DOB
19. Child's Preferred Name
20. Child's Current Grade Level*
22. Gender*

    1. Male
    2. Female
    3. Other

    Please note below if other

23. Native American Child?*

    1. Yes
    2. No
    3. Unknown
24. Past County Involvement?*

    1. Yes
    2. No
    3. Unknown
25. Is the child currently on probation?*

    1. Yes
    2. No
    3. Unknown
27. Child's Home Address*
29. City*
30. State*
31. Zip Code*
33. Credits Earned to Date*

    Type N/A if not a high school student

34. Credits Required to Graduate*

    Type N/A if not a high school student

35. On Track to Graduate?*

    1. Yes
    2. No
    3. Not a high school student
36. Anticipated Graduation Date*

    Type N/A if not a high school student

40. #1 Parent/Guardian Name*
41. Custody Status

    1. Full Custody
    2. Joint Legal and Physical
    3. Joint Legal Only
    4. Joint Physical Only
    5. Unknown
43. Address*
45. City*
46. State*
47. Zip Code*
49. Email Address
50. Phone Number*
54. #2 Parent/Guardian Name
55. Custody Status

    1. Full Custody
    2. Joint Legal and Physical
    3. Joint Legal Only
    4. Joint Physical Only
    5. Unknown
57. Address
59. City
60. State
61. Zip Code
63. Email Address
64. Phone Number
68. Last Unexcused Abscence*
    Last Unexcused Abscence
69. Describe all efforts completed by the school to address attendance concerns with the child and parents/guardians*
71. Upload Proof of Efforts Completed by School*

    Truancy Required -  Copy of School Support Plan

    All Referrals Required - Copy of 3 and 5 day letters

    Copy of Attendance Policy (Required for all online schools)

    Please submit as one file

72. Upload Attendance Records*

    Include an explanation of codes & highlight dates of unexcused absences

    
    

74. Additional Information
75. Other Applicable Documents

    Examples:

    Letter notifying parent(s) of required medical documentation

    Individual Education Plan (IEP)

    504 Accommodation Plan

    Current Disciplinary Record

76. Other Applicable Documents

    Examples:

    Letter notifying parent(s) of required medical documentation

    Individual Education Plan (IEP)

    504 Accommodation Plan

    Current Disciplinary Record

77. Other Applicable Documents

    Examples:

    Letter notifying parent(s) of required medical documentation

    Individual Education Plan (IEP)

    504 Accommodation Plan

    Current Disciplinary Record

Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field