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The information provided in this section of the truancy referral is to provide us with the contact information for the person that is submitting the truancy referral.
Please enter your full name
Examples: Principal, Assistant Principal, Dean, School Social Worker, Teacher, Attendance Clerk.
(555) 555-5555 or 555-555-5555
Please enter your email address, so we may contact you.
In this section, please let us know if there is someone that you would like us to contact directly for attendance update requests. This section is not required, but is helpful.
Please use the list of Lake County districts and schools. The list for the schools is to be selected based on the school or Special Education/Alternative placement the student attends. For example, if the student is enrolled at Zion Benton High School, but physically attends Cyd Lash Academy, then you would select Cyd Lash Academy.
If your school is not on here, please contact Andrea Kowitz at (847) 752-0169 or by email: email@example.com. Please keep in mind that if you are a private placement or therapeutic day school, the truancy referral must come from the home district. The only exceptions to this rule are SEDOL and NSSED, as they are considered to be public school districts providing Special Education services.
Please select from the list.
The information provided in this section is to primarily provide the demographic background of the student. It is also to provide us with the proper contact information for the parents.
Only check off one. If you feel they should have more than one, select "two or more races".
Only answer if the student was ever retained. If student has been retained multiple years, please make a special note of that in the comment section.
We ask this question because juvenile delinquency charges supersede truancy. If they are currently court involved (not including municipal or family court), this may change services that ATD can provide.
Please check off the primary category of services the student receives.
Please check off one if the student has a secondary category that they receive services for.
Does the student receive services under a 504 Plan?
SIS #: The State Identification number is a 9 digit unique number issued in IWAS by ISBE. Please note: this is not the District Id number. SIS numbers will not contain the year that the student is anticipated to graduate from high school, and will not have three or more consecutive zero's. If you are unaware of where to locate the SIS number, please contact someone in your IT department, or front office.
Spanish Letter: Please check off whether or not the student's family needs a Spanish Letter. Also, if the student receives ESL or ELL services.
TANF: Please check off whether or not the family receives any kind of TANF assistance from DHS (i.e. Cash, Snap, Medical Assistance).
If the student is in High School, please select N/A
Please check off whether or not the family receives free or reduced lunch at school.
Please enter the primary address on record for where the student resides.
Please enter any secondary address on record for another custodial parent and/or guardian.
In this section, please identify the primary and secondary parent/guardian
Please enter the full names that the student lives with. This will be who we address any of the correspondence to.
Example: John Doe, Jane Doe
Example: John Doe, Jane Doe
What is the relationship of the custodian(s) to the student (i.e. Parents, Mother, Father, Grandmother, Guardian, Uncle)?
Attendance and Services Documentation
Please enter the data based on the current school year. The Date Enrolled is also referring to this school year. That helps us to see if they enrolled on time or not. The attendance reported should be in full and half day increments (not by class periods). Due to ISBE reporting, our database will round to the nearest whole number.
Please review the cumulative file to locate the history of absences for the student and enter the data below. This information is required. Entering a "0" will initiate a request from ATD after the referral for the missing information. Please provide a note in the "comment section" of why you are unable to provide this information.
Refers to the whole 4 years required. Examples of local schools would be: 22, 23, 22.5, 41.
Refers to the number of credits that they have earned so far in their High School career.
Refers to the total number of credits the student is attempting right now, as you are completing the truancy referral.
Check all that apply
Please check off any of the following barriers you are aware of that is preventing the student from attending school.
Please send the following backup documentation to ATD by either fax or email: Current Year Attendance Report, Cumulative Card showing history of attendance/grades, Any other documents you feel would be helpful in working with the student. The fax number is (847) 223-3415, or the email address is firstname.lastname@example.org. Thank you for your cooperation.
Please use this box to enter your digital signature. This will represent your legal signature, consenting the truancy referral to ATD. This will also pertain to any requests by ATD staff members for attendance and grade updates, whether it is within the home school, or any special education/alternative placements (IE: Ombudsman, Connections, Learning House).
This field is not part of the form submission.
* indicates a required field