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