Name: � DOB: Grade: Race: Gender: AOC-JV-38.1 � Doc. Code: ABCSE Rev. 3-17 � Juv Id: Page 1 of 2Commonwealth of KentuckyCourt of Justice www.courts.ky.govFCRPP40 lexet justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE School: � SSN: Mother: � Father: Demographic Information: CDW Referral No. Case No. Court � [ ] Family � [ ] District County Other Legal Guardian(s): � Relationship: Student resides with: (Please check all that apply) MotherMother's Resident Address:Mailing Address(if different than above):Total Absences: Absences Unexcused: Total Tardies: Tardies Unexcused: Home Phone: Cell Phone: Work Phone: FatherFather's Resident Address:Mailing Address(if different than above): Home Phone: Cell Phone: Work Phone: Other/Legal GuardianOther/Legal Guardian Resident Address:Mailing Address(if different than above): Home Phone: Cell Phone: Work Phone: Truancy Information: Both ParentsParent's Resident Address:Mailing Address(if different than above): Home Phone: Cell Phone: Work Phone: Skipping School � Skipping Classes � Behavior Issues Low Academic Performance � Suspensions (# of events ) � Suspected Gang Involvement Suspected Drug Involvement � Suspected Alcohol Use � Bullying Poor Peer Relationships � Tobacco Use � Safety Concerns/FightingDescribe School Concerns: School Issues: (Please check all that apply) AFFIDAVIT AND BEYOND CONTROL OF SCHOOL EVALUATION FORM 504 Plan � IEP (Last ARC Date: ) American LegalNet, Inc. www.FormsWorkFlow.com This form was: Prepared by: � � � � I, , the undersigned Aand that the matters stated herein are true to the best of my information, knowledge, and belief. � � Signature � � Printed name � SWORN TO before me this day of , 2.Name � Title AOC-JV-38.1Rev 3-17Page 2 of 2 � Name � Title Phone No. and Email � Date . Phones Calls to Parent � Referral to Youth Services Center (FRYSC) Letters Sent to Parent � Referral to Guidance Counselor Parent Conference � Referral to Social Services Student Conference � Referral to Mental Health Services Home Visits � Referral to Medical Services Other Interventions: � List of Attachments: � Attendance Record of Unexcused Absences/Tardies � Discipline Report � Grade Report American LegalNet, Inc. www.FormsWorkFlow.com