Truancy Intervention Referral Form

OFFICE OF BLUE EARTH COUNTY ATTORNEY PATRICK R. MCDERMOTT

COUNTY ATTORNEY
BLUE EARTH COUNTY TIP MEETING REFERRAL FORM
Student Name
DOB

MonthDayYear
Age
Gender:
School
Other School
Grade
Mother/Guardian
Custodial Parent:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone

Area CodePhone Number
Email
example@example.com
Father/Guardian
Custodial Parent:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone

Area CodePhone Number
Email
example@example.com
Primary Language at Home
Hearing Impaired Interpreters Required:
*REFERRALS WILL NOT BE PROCESSED WITHOUT A COMPLETE ADDRESS*

Please attach student's attendance record with the student identification number redacted.
School Referring and Address
Telephone Number

Area CodePhone Number
Contact Person
Meeting Date/Time/Location
Attach Attendance Records:

Cancelof
When submitting this form. It will be received by attorney.truancy@blueearthcountymn.gov.

If you have any questions or concerns, please contact the Blue Earth County Attorney's Office at attorney.truancy@blueearthcountymn.gov.

OFFICE OF BLUE EARTH COUNTY ATTORNEY PATRICK R. MCDERMOTT