Attendance Referral Form

Lebanon Special School District

"Committed to a Community of Excellence"

Attendance Referral Form (For School Use Only)
School Name:
Teacher:
Student Name:
Address:
Guardian:
Phone Number:
Work Number:
Translator Needed?	Yes No
Reason for Referral:	Excessive Absences (How Many? ) Excessive Tardies (How Many? ) Excessive Early Releases (How Many? ) Other (Please Provide Explanation Below)
Actions Taken Prior to Referral:	Conference(s) with Parent/Guardian Letter Contact by Phone Other (Please Indicate)
Additional Comments:
Person Making Referral:
Position:
Date:

Lebanon Special School District - 701 Coles Ferry Pike - Lebanon, Tennessee 37087
Phone: 615.449.6060 - Fax 615.449.5673