Submit a Truancy Referral (School Staff & Community Agencies)

Youth's Name *

First

Last

School Name

Where youth is currently enrolled. If currently unenrolled, please enter the school the youth is zoned for based on youth's home address.

Student Number *

If unknown, please type in 0

Youth's Grade *

Number of School Days Missed This Year *

Date of Birth *

Gender *

Race

Hispanic Origin

Parent/Guardian's Name *

Language

Address *

Address Line 1

City

State

Zip Code *

Parent/Guardian's Phone *

Notes

CCSD Release of Information (Optional)

Click or drag files to this area to upload. You can upload up to 3 files.

CCSD Staff: Please submit a completed release of information if you request to receive information regarding the appointment.