Fill and Sign the Complaint School Truancydefiance Family with Service Needs Form

NAME OF GUARDIAN, IF ANY COMPLAINT - SCHOOL TRUANCY/DEFIANCE FAMILY WITH SERVICE NEEDS JD-JM-119 Rev. 10-07 C.G.S. §§ 46b-120, 149, 10-198a, 10-200 Spec. P.A. 07-4, Sec. 30 STATE OF CONNECTICUT SUPERIOR COURT NAME OF CHILD DOCKET NO. JUVENILE MATTERS THE ABOVE FAMILY IS A FAMILY WITH SERVICE NEEDS BECAUSE IT INCLUDES A CHILD WHO IS (PLACE AN "X" IN THE APPROPRIATE BOX(ES)): NAME OF SCHOOL AND CONTACT PERSON AT SCHOOL ADDRESS OF COURT NAME OF MOTHER NAME OF FATHER NAME OF COMPLAINANT TYPE OF REFERRAL TRUANT (Four (4) unexcused absences in one month or Ten (10) unexcused absences in a school year) HABITUALLY TRUANT (Twenty (20) unexcused absences in a school year) DEFIANT (Continuously and overtly defiant of school rules and regulations) ADDRESS OF MOTHER ADDRESS OF FATHER ADDRESS OF GUARDIAN ADDRESS OF COMPLAINANT TELEPHONE FAX NO. DATE OF BIRTH SEX ADDRESS OF CHILD (Page 1 of 2) MOTHER'S HOME TEL. GUARDIAN'S WORK TEL. MOTHER'S WORK TEL. FATHER'S HOME TEL. FATHER'S WORK TEL. GUARDIAN'S HOME TEL. GRADE INDIAN TRIBE/RESERVATION, IF ANY A family with service needs complaint may be filed only after the school has exhausted all available options to rectify the problem. A complaint may be found insufficient if it does not include the following as required by state law including but not limited t o C.G.S. Sec. 10-198a: ("X" box if action as been taken) A meeting was held with the parent of the child who is truant and appropriate school personnel reviewed and evaluated the reasons for the child being truant and such meeting was held not later than ten school days after the child's fourth unexcused absence in a month or the tenth unexcused absence in a school year. Coordination of services and referrals for said child were made to community agencies providing child and family services. Parent was annually at the beginning of the school year and upon any enrollment during the school year, informed in writing of the obligations of the parent or other person having control of the child pursuant to C.G.S. Sec. 10-184. Reasonable efforts to notify, by telephone, the parent or other person having control of the child were made by school personnel whenever said child failed to report to school on a regularly scheduled school day and no indication was received by school personnel that the child's parent or other person having control of the child was aware of the pupil's absence. If records are incomplete or do not exist please attach an explanation for the Cour\ t. www.jud.ct.gov SIGNED (Superintendent of School, only) PRINT OR TYPE NAME OF PERSON SIGNING JD-JM-119 Rev. 10-07 (Page 2 of 2) DATE SIGNED LIST SPECIFIC DATES OF UNEXCUSED ABSENCES IN THE SPACE BELOW. DO NOT JUST REFERENCE THE INCLUDED ATTENDANCE REPORT IN THIS SECTION. ATTENDANCE IF THIS REFERRAL IS BASED ON THE CHILD'S IN-SCHOOL CONDUCT RATHER THAN TRUANCY, PROVIDE DOCUMENTATION THAT THE CHILD HAS BEEN CONTINUOUSLY AND OVERTLY DEFIANT OF SCHOOL RULES AND REGULATIONS. THERE MUST BE A PATTERN OF DEFIANCE OVER TIME. A SINGLE INCI DENT IS NOT SUFFICIENT TO ESTABLISH THAT A CHILD IS DEFIANT OF SCHOOL RULES. (List all dates and description of behavior) BEHAVIOR LIST DATE(S) OF MEETING(S) WITH PARENT(S): Parent or guardian failed to attend meeting(s) on or otherwise failed to cooperate with the schoo l in attempting to solve the truancy problem. Community Services attempted on: Has the parent/guardian been notified of the filing of this complaint? Yes No