Fill and Sign the Request for Custody by School Attendance Officer Designation by School District Administrator Wisconsin Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE INTEREST OF       Name Request for Custody by School Attendance Officer/ Designation by School District Administrator       Date of Birth Case No.       Request for Custody by School Attendance Officer 1. I am the school attendance officer for the       School District. 2. The juvenile is absent f rom school without an acceptable excuse. The previous attendance record of the juvenile is as follows:             See Attached 3. I request that the juvenile be taken into custody by a person desig nated by the school district administrator. Signature of School District Administrator       Date Designation by School District Administrator Based on the request of the school attendance officer, I direct the following person(s) take the juvenile into custody: Those persons previously designated by me pursuant to a blanket authorization issued on       . Date The following individual(s): 1. An employee of the district who is directly involved in the provision of educational programs for the truant child:       2. An employee of the district who is directly involved in the provision of a modified program or curriculum, a program for children at risk, an alternative educational program, or any other alternative educational program to children who attend the school attended by the truant child:       3. A school social worker employed by the district who provides services to children attending the school attended by the truant child:       4. An employee of a social services agency who is directly involved in the provision of social services to the truant child or the child's family:       5. The school attendance officer:       I have attempted to notify by personal contact or telephone the juvenile's parent, guardian and legal custodian that I have designated individual(s) for the purpose of taking the juvenile into custody. Such attempt was successfully made: by phone in person on       at       . Date Time unnecessary because the parent, guardian, or legal custodian is the person who requested that the juvenile be taken into custody. Upon taking the juvenile into custody, the person shall: • determine if the juvenile may be released under §938.20, Wis. Stats.; and • if release is not appropriate, deliver the juvenile to juvenile intake. JD-1703 , 05/00 Request for Custody by School Attendance Officer/ Designation by School District Administrator §§118.16(2m)(a), 938.19(1m), 938.20, Wis. Stats. This form shall not be modified. It may be supplemented with additional material. Request for Custody by School Attendance Officer/ Designation by School District Administrator Page 2 of 2 Case No. Distribution: 1. Original – School District Administrator 2. Person taking juvenile into custody 3. Parent/guardian/legal custodian Signature of School District Administrator       Date JD-1703 , 05/00 Request for Custody by School Attendance Officer/ Designation by School District Administrator §§118.16(2m)(a), 938.19(1m), 938.20, Wis. Stats. This form shall not be modified. It may be supplemented with additional material. Page 2 of 2