Gooding Joint School District No. 231
STUDENTS 3040F2
SCHOOL TRUANCY REFERRAL FORM PART I:
Student
(last name) (first name) (middle name)
Grade Age DOB Sex Race Language
Mother’s Name Phone Wk Phone
Mother’s Address City Zip DOB
Father’s Name Phone Wk Phone
Father’s Address City Zip DOB
Child resides with _
Address (if different than above) Zip Phone
PART II:
Enrollment Date: Number of Tardies:
Number of Absences without Valid Excuse: Number of Absences with Valid Excuse: Dates Child was Absent from School without Valid Excuse:
Suspension/Expulsion Dates:
Contacts with Parents, Actions Taken, and Outcomes (attach additional sheets if necessary):
Date: Date: Date: Date:
Advisory Letter Sent? No
Yes
Date:
School Representative (person who can testify to the identification of the child, enrollment, keeping of records, and content of records):
PART III: REFERRING SCHOOL INFORMATION
School Name Address City & State
District Telephone Zip
Print name of person submitting report Title and Position
Phone Signature