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Truancy Diversion Form 16 - 17 1/2 Year Olds

  1. Gender:*

  2. Race:

  3. Interpreter needed?*

    Please be advised - it is the responsibility of the school to provide an interpreter if needed.

  4. STUDENT LIVES WITH:

    Enter complete parent/guardian information

  5. 1. REQUIRED PRE-REFERRAL EFFORTS

  6. For the above field, please include the dates and a brief description of the pre-referral efforts taken.

  7. Is this student a transfer from another county?

  8. Is this student being considered for a 15 day drop?

  9. Attendance History:

  10. (probation, child protection, mental health, etc.):

  11. 2. ACADEMIC/BEHAVIOR/SPECIAL EDUCATION

  12. Receives Special Education Services:

  13. Primary Disability:

  14. ESL:

  15. (include grades, behaviors, other issues, etc.)

  16. 3. OTHER HEALTH ISSUES

  17. Mental Health Issues:

  18. Chemical Health Issues:

  19. Please remember to attach the student's current attendance record.

  20. Leave This Blank:

  21. This field is not part of the form submission.