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Kent ISD
Truancy and Expulsion Form Submission

Attendance Affidavit and Referral Form^TM

School Information

School Type

District of Residence

District

School

Principal

(not Vice or Assistant)

Submitted By

Submitter's Title

Phone

2nd Email

** Date Parent / Guardian was notified by a local school administrator by letter or telephone call.
Michigan Law requires this notification before referral to the Kent ISD Office of Truancy and School Attendance.

Notification Date

Notified By

Notifier's Title

Student Information

Student UIC

Legal First Name

Legal Middle Name

Legal Last Name

Preferred First Name

Preferred Middle Name

Preferred Last Name

Gender

Male Female

Preferred Pronoun

Pref Pronoun Comment

Does the student have a current IEP?

Yes No

*** Please attach the IEP to this referral ***

Does the student's disability impact their attendance?

Yes No

Primary Disability

Birth Date

Grade

Instruction Type

Please explain "Other" in comments section

Because the student is 16.5+ years old, please provide the following required information:

Is student credit deficient?

Yes No

Is it likely student will graduate with their cohort?

Yes No

Race

Street Address

Apartment/Lot/Suite

City

State

Zip

Is student experiencing homelessness?

Yes No

Has the McKinney-Vento grant been offered to the family?

Yes No

Services Offered

This student is subject, by age, to the MI compulsory attendance law.

Yes No

Student has work permit

Yes No

Employer

Is student not attending and location is unconfirmed or unknown?

Yes No

Is student reported as a Runaway?

Yes No

Additional information about missing student

Are there any known siblings in the district?

Yes No

Sibling Name(s)

Sibling Building(s) and any other helpful information

Parent / Legal Guardian 1

Title

Mr. Mrs. Ms.

First Name

Last Name

Birth Date

Primary Phone

Parent/Guardian is fluent in English

Yes No ¹

Primary Language

¹If no, it is the school's responsibility to translate to the family.

Employer

Work Phone

Parent / Legal Guardian 2

Parents/Guardians share an address

Yes No

Title

Mr. Mrs. Ms.

First Name

Last Name

Birth Date

Primary Phone

Street Address

City

State

Zip

Has educational info rights

Yes No

Parent/Guardian is fluent in English

Yes No ²

Primary Language

²If no, it is the school's responsibility to translate to the family.

Employer

Work Phone

Referral Information

Attendance Improvement Plan (AIP) Contact

AIP Completion Date

Days Possible

Scheduled Days at Time of Referral

Snow Days / School Closures

Days Suspended

Other Uncounted Absences

i.e. Exceptional medical (such as hospitalizations, funerals & court) -- DO NOT include COUNTED ABSENCES

Total Days Possible as of

Absences

You must choose the method used to calculate how time was lost.

How Lost Time Calculated

Lost Learning Time (LLT) due to COUNTED absences only. Does not include tardies, early departures, etc.
Total Lost Learning Time (TLLT) including COUNTED class period absences, tardy class periods, late arrivals and early departures

Counted Absences

When is attendance collected

Attendance is collected twice a day
Attendance is collected each class period (6 hour day)

Full-day absent	F
Each half-day absent	A	91 minutes or more
Each day tardy	T	Tardy, 35 minutes or less
Each day late	L	Late arrival, 36-90 minutes
Early departure	D	Early departure, 35 minutes or less
Extra early departure	Z	Extra early departure, 36-90 minutes

	Full-day absent	F
	Each Class period Absent (not including full days)	A
	Each Class Period Tardy	T
	Each Day Early Departure	D

Total Lost Learning Time to Date

Additional Comments

Attach intervention document(s) once you submit your referral. Any additional notes we should be aware of please enter here.

By checking this box, under penalties of perjury, I declare that I have examined this affidavit and any accompanying statements or attachments, and to the best of my knowledge and belief, they are true, correct and complete.

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Kent ISDTruancy and Expulsion Form Submission

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Attendance Affidavit and Referral FormTM

Uncounted Absences

Kent ISD
Truancy and Expulsion Form Submission

Attendance Affidavit and Referral Form^TM